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Home , Presbyopia

Acta Ophthalmologica 2014

Review Article

Review of the impact of presbyopia on quality of life in the developing and developed world

Ariana D. Goertz,1 William C. Stewart,2 William R. Burns,3 Jeanette A. Stewart2 and Lindsay A. Nelson2

1University of Nevada, Las Vegas, Nevada, USA 2PRN Pharmaceutical Research Network, LLC, Cheyenne, Wyoming, USA 3Encore Vision, Inc., Fort Worth, Texas, USA

ABSTRACT. (Barbero 2013). Everyone eventually Purpose: To examine the public health impact of presbyopia regarding its effect develops presbyopia but symptoms on quality of life (QoL) and society in both the developed and developing worlds. may vary. The major risk factor for Methods: A database was created from articles found on PubMed, the Cochrane presbyopia is age although the condi- Library and Science Direct using the following search terms: presbyopia, QoL, tion may be affected by other factors , impact, cost, prevention, treatment and public health. Articles including disease, trauma and medica- were accepted into the database if they addressed presbyopia and public health. tions (American Optometric Associa- Results: This study showed in the developed world presbyopic subjects treated tion 2010). with reading suffered a reduction in QoL parameters compared with Presbyopia is classically believed to those who were younger and emmetropic. A small minority of subjects were result from hardening of the although other causes have been assessed to be a candidate for additional non-spectacle treatment measures. In described as well such as changes in undeveloped areas, the manifestations of presbyopia were similar to the tissue elasticity and the developed world in symptoms, age and reduced QoL. However, there was (Weale 1962; Glasser et al. 2001; inadequate treatment of this condition, even with reading glasses. The Heys et al. 2004; Strenk et al. 2005; availability of reading glasses ranged from 6 to 45%. Activities of daily living McGinty & Truscott 2006; American could not be accomplished as easily without near correction of reading. Reasons Optometric Association 2010). An described for the lack of correction included: lack of access to medical care, poor important contribution to presbyopia awareness of decreased near vision, lack of motivation and cost. Overall scant is loss of lens viscoelasticity and lens data exist regarding presbyopia and its impact and how treatment affects QoL. growth that accompanies advancing Conclusions: This review suggests that the effect of presbyopia and its age (Burd et al. 2006). This loss of treatments on QoL remain poorly described and incompletely treated, especially lens elasticity may be at least in part in developing areas of the world. due to oxidized protein sulphydryl groups within lens fibre cells from Key words: presbyopia – public health – quality of life – treatment intraprotein cross-links that, over time, contribute to accommodative amplitude loss (Garner & Spector Acta Ophthalmol. 2014: 92: 497–500 1980; Lou & Dickerson 1992; Takem- ª 2013 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd oto 1996; Bron et al. 2000; Hanson doi: 10.1111/aos.12308 et al. 2000; Lou 2003). Lens growth increases the inelastic mass that must change shape for accommodation to Introduction dation diminishes, the range of clear occur. vision may become inadequate for the Current treatments are corrective in Presbyopia is an age-related visual subject’s commonly performed near nature either by optical (, trifo- impairment that results from the grad- tasks. Presbyopia has been a known cals or contact ) or surgical ual decrease in accommodation affliction since ancient times and gen- (accommodative intra-ocular lenses or expected with age and may affect erated enough problems in society that laser or conventional corrective surgi- quality of vision and quality of life Plutarchus speculated to its mechanis- cal techniques) refractive modification. (QoL). As the amplitude of accommo- tic causes as long ago as 100 AD No current pharmaceutical treatment

497 Acta Ophthalmologica 2014 or remedy exists that reverses the vision health-related QoL. Monovision (Maxwell et al. 2008). The acquisition natural of the lens. For a correction of presbyopia improved some cost associated with bilateral implan- condition that affects every adult, with measures of QoL, but it remained worse tation of two MF-IOLs was estimated a potentially deep lifestyle impact, very in younger subjects with at $4000. Of the sample, 86% in the little information is available about the (McDonnell et al. 2003). MF-IOL and 8% in the monofocal QoL or financial impact of presbyopia Luo et al. (2008) demonstrated in a IOL group reported postoperative on society. cross-sectional study in 110 American spectacle independence. The net cost- The purpose of this review is to patients that presbyopia corrected with benefit of $11 670 in the MF-IOL examine the public health impact of glasses was associated with a nominal group exceeded the $155 net benefit in presbyopia regarding its effect on QoL decreaseinQoL,similartothatoftreated the conventional monofocal IOL group and society in both the developed and hypertension. Approximately 10% of over a period of 14 years. developing worlds. these patients suffered such inconve- Exploring a non-surgical correction nience from presbyopic correction that technique Polat and associates, in 30 Materials and Methods theymighthavebeencandidatesfornon- Israeli subjects, observed that percep- spectacle surgical intervention (Luo tual training tasks improved on average et al. 2008). Also, Spierer and Shalev, by about 17 words/min reading speed in Study criteria inaclinicaltrialof100healthyhyperopic presbyopes with uncorrected near vision The database was created (ADG) from Israelisubjects,notedthatlowamplitude (Polat et al. 2012). After training, a articles published between 2002 and 28 of accommodation at the age of 20 might presbyope would save approximately February 2013 found on PubMed predispose to earlier onset of presbyopia nine minutes when reading a 2000 word (www.pubmed.gov), Science Direct (Spierer & Shalev 2003). article at the smallest font size. (www.sciencedirect.com) and The Coch- In contrast, Leat and Mohr demon- rane Library (www.thecochranelibrary. strated that pre-presbyopes with prior Quality of life in the developing world com) using the following search terms: , including children, presbyopia, QoL, accommodation, eco- had reduced accommodation (Leat & Patel et al. (2006) found in a cross- nomics, impact, cost, prevention, treat- Mohr 2007). Using a case–control sectional survey in 1564 African sub- ment and public health. Complete study, the authors examined 21 Cana- jects > 40 years of age that the preva- English language articles were dian low-vision patients with a variety lence of presbyopia was 62%. The retrieved, and studies were accepted of ocular conditions and indicated that majority of presbyopes (94%) did not into the database if they addressed the near visual deficit increased with have corrective near-vision glasses. presbyopia and public health. No spe- increasing accommodative demand. Compared with younger subjects, pres- cific exclusion criteria were defined for Several articles have investigated the byopia increased the odds of any dif- the study. change in QoL following refractive ficulty with near-vision tasks by Search terms (specified above) were treatment for presbyopia. Richdale twofold and the odds of having a searched twice in all utilized databases. and associates prescribed a difficulty with very demanding near- All articles meeting the above criteria for an eye with a previously implanted vision tasks by >eightfold. The degree were used in the analyses. Searches intra-ocular lens (IOL). The target of presbyopia was associated with were quality checked by two of the for distance was emmetr- increasing difficulty with daily tasks other authors (LAN and WCS). The opia. They found at baseline, and after (Patel et al. 2006). authors must have agreed that the 1-month of contact lens use in 38 US Laviers et al. (2010) found in a article fulfilled the entry criteria. patients who completed the NEI-RQL cross-sectional, population-based study Data from articles meeting the study survey, that most (76%) preferred the of 381 Africans >40 years of age that criteria data were entered into an multifocal [SofLens Multi-Focal the prevalence of presbyopia was 89% Excel spreadsheet for each treatment. (polymacon) Visibility Tinted Contact (n = 340) and spectacle coverage was The ‘developed world’ data were Lens; Bausch & Lomb, Rochester, NY, 18% (n = 60). Barriers to accessing compiled from studies in Canada, USA] compared with monovision [Sof- services included spectacles not being France, Israel, Spain and the United Lens 59 (hilafilcon B) Visibility Tinted considered a priority by the patient and States. The ‘undeveloped world’ data Contact Lens; Bausch & Lomb] intra- insufficient funds to pay for glasses. At were collected from studies in Africa, ocular lens (IOL) correction alone follow-up, 175/187 (94%) of partici- Brazil, India, Nigeria, Saudi Arabia, (Richdale et al. 2006). The basis of pants given spectacles still had them. Tanzania, Thailand and Timor-Leste. the preference appeared to result from Average satisfaction was 90%. The the better vision and stereoacuity. mean amount subjects were willing to Results Stereoacuity was 158 Æ 220 seconds pay for spectacles increased from $2 at arc at baseline, 126 Æ 137 seconds arc baseline to $3 at follow-up. Æ Quality of life, developed world with multifocals and 205 214 sec- Bekibele & Gureje (2008) evaluated onds arc with monovision (p = 0.002). 5587 Africans >65 years of age by McDonnell et al. found, using the Maxwell et al. evaluated by cost-bene- completing the World Health Organi- National Eye Institute fit analysis of multifocal IOLs (MF- zation Quality of Life assessment Quality of Life instrument (NEI-RQL) IOL) and noted, in 495 American instrument and noted that 453 (22%) in 38 older (≥45 years) versus 75 younger surgery patients, that 86% of reported difficulties with distant vision, (<45 years) emmetropic Americans that patients were willing to pay at least $5 377 (18%) had difficulties with near presbyopia was associated with reduced per day to be spectacle independent vision and 312 (15%) reported difficul-

498 Acta Ophthalmologica 2014 ties with both far and near vision. spectacles, 2085 (76%) had difficulty Discussion Impairment of near vision had a sig- recognizing small objects, and 1057 nificant impact on all domains of QoL (38%) stated they were unable to This study showed that subjects with including physical, psychological and manage any near work. Ramke et al. presbyopia suffered reduced QoL both social environments of daily life. Dis- (2007) also used population- in the developed and developing world. tant vision demonstrated a significant based cross-sectional surveying to In the developed world, several articles decrement only in the domain of envi- investigate presbyopia in 1414 subjects showed that presbyopic subjects trea- ronment. After adjusting for the possi- with ages >40 in East Timor in South- ted with reading glasses suffered a ble effects of age, sex and chronic East Asia. A total of 32% (n = 457) reduction in QoL parameters com- physical illness, near-vision impairment participants having under-corrected or pared with those who were younger accounted for 4% decrease in the uncorrected near vision were classified and emmetropic. A minority of sub- overall QoL of elderly persons. as having an ‘unmet presbyopic need’. jects were assessed to be a candidate for Sherwin et al. (2008) found using a The presbyopia correction coverage additional non-spectacle treatment cross-sectional survey in 111 African was 26%. Lower correction coverage measures. subjects ≥50 years old, analysed by was associated with rural domicile, Overall there remains a lack of data testing near vision, that the unmet illiteracy and farming. regarding the impact on QoL from presbyopic need was 80% and the Vincent (2006) evaluated treating presbyopia- and treatment-related needs of presbyopic correction were refractive errors in a rural adult pop- QoL. This is a surprise to the authors fully satisfied in 5%. The authors ulation of refugees living along the because this condition affects nearly believed that in low-income regions a Thailand–Burma border, to whom every middle-aged and older adult high prevalence of uncorrected presby- were distributed 7219 eyeglasses. throughout the global community, opia exists, which is associated with Approximately 84% of corrective although or may near-vision functional impairment. lenses were for presbyopia. The spec- limit symptoms in some adults. In Brazil, Duarte et al. (2003) studied tacle provision rates per 100 000 per- Most QoL-related studies reviewed 3007 subjects >30 years old by cross- sons were 4284 for presbyopia. Eye were performed in the developing sectional surveying and observed a prev- care training was provided to local world, particularly in Africa and Asia. alence of presbyopia of 55%. The great- refugee healthcare workers, which The authors found generally in undev- estincreaseinprevalencebyageoccurred allowed for effective sustainable, low- eloped areas that the manifestations of between the ages of 35–39 and 40– cost spectacle provision to a large presbyopia were similar to the devel- 45 years (from 11% to 28%) as well as population over an extensive geo- oped world in symptoms, age and from 40 to 44 and 45 to 50 years (28% to graphic area in a challenging environ- reduced QoL. 66%). They noted a linear trend between ment. The authors concluded that However, in the developing world, age and the increase in presbyopia. spectacle distribution programme there was a lack of treatment or under- In Asia, Marmamula et al. (2011) could be implemented in areas where treatment of this condition, even with observed in 3095 Indians that among lack of resources or lack of technical reading glasses, that is assumed gener- the 974 subjects >35 years, evaluated support would prevent acquisition. ally in the developed world to be the using the Rapid Assessment of Refrac- Lu et al. (2011) found in 776 Chi- easiest treatment intervention. The tive Errors survey, presbyopia was nese >40 years using population-based range of availability of reading glasses present in 616 (63%) and was uncor- cross-sectional surveying that the 538 in these studies was from 6% to 45%. rected in 512 (83%). The most fre- (69%) persons with presbyopia dem- In addition, several studies noted a quently cited barrier to utilizing onstrated worse self-rated (distance reduction in QoL measures because services was the lack of ‘felt need’ in and near) vision and greater difficulty activities of daily living could not be 237 (46%) for correction. ‘Lack of with activities of daily living than accomplished as easily without near awareness’ of presbyopia symptoms younger subjects. Odds of reporting correction of reading. One study indi- was reported by 82 (16%) of partici- any difficulty with daily tasks cated a host of factors for the lack of pants. Also, ‘lack of access’ and eco- remained higher for presbyopes after correction including: lack of access to nomic and personal reasons were adjustment for age, sex, education and medical care, poor awareness of reported by 13%, 13% and 12%, distance vision. Compared with non- decreased near vision, lack of motiva- respectively. Spectacle correction for presbyopic persons, presbyopes more tion and cost. presbyopia was 19%. often reported diminished accomplish- What is the clinical significance of Further, Nirmalan et al. (2006) in a ment in terms of household activities, this review? The lack of data indicates, population-based cross-sectional study, social interaction, work and leisure both in the developing and developed determined the prevalence of presbyo- time pursuits. Of the presbyopes, 65 worlds, more research is needed to pia in southern India in 5587 subjects (12%) reported requiring help from better quantify the problems related ≥30 years was 70% (n = 3907). Twenty others, 80 (15%) and 46 (7%) stated to presbyopia and ways to most effec- per cent (n = 364) of the 3907 subjects feeling ashamed or embarrassed due to tively treat it in a cost effective manner. with presbyopia reported the onset of poor vision. In this study, the presby- In addition, research to discover ave- noticeable symptoms during these opia-related limitations caused partic- nues of new treatment, both pharma- years. They noted an effect on perform- ipants to restrict social interaction, ceuticals and devices, which would ing activities related to near-vision household and leisurely activities due reverse the condition instead of cor- tasks. Of the 3907 with presbyopia, to shame and embarrassment of vision recting by refractive means, might also 2734 (70%) were not currently using problems. benefit presbyopic subjects.

499 Acta Ophthalmologica 2014

Further, better cost analyses of cur- Burd HJ, Wilde GS & Judge SJ (2006): Can related quality of life. Arch Ophthalmol rent and new treatments would help reliable values of Young’s modulus be 121: 1577–1581. private and government policy makers deduced from Fisher’s (1971) spinning lens McGinty SJ & Truscott RJ (2006): Presbyopia: – to decide on the best treatments to offer measurements? Vision Res 46: 1346 1360. the first stage of nuclear cataract? Ophthal- Duarte WR, Barros AJ, Dias-da-Costa JS & mic Res 38: 137–148. to presbyopic subjects in poorer areas. Cattan JM (2003): Prevalence of near vision Nirmalan PK, Krishnaiah S, Shamanna BR, In these areas, the lack of spectacles also deficiency and related factors: a population- Rao GN & Thomas R (2006): A population- provides opportunity and challenges for based study. Cad Saude Publica 19: 551– based assessment of presbyopia in the state religious-based charities and govern- 559. of Andhra Pradesh, south India: the Andhra ment agencies to assist developing areas. Garner MH & Spector A (1980): Selective Pradesh Study. Invest Ophthal- This review suggests that the effect oxidation of cysteine and methionine in mol Vis Sci 47: 2324–2328. of presbyopia and its treatments on normal and senile cataractous lenses. Proc Patel I, Munoz B, Burke AG, Kayongoya A, – QoL remain poorly described and Natl Acad Sci USA 77: 1274 1277. McHiwa W, Schwarzwalder AW & West SK Glasser A, Croft MA & Kaufman PL (2001): (2006): Impact of presbyopia on quality of incompletely treated, especially in Aging of the human crystalline lens and life in a rural African setting. Ophthalmol- developing areas of the world. presbyopia. Int Ophthalmol Clin 41:1–15. ogy 113: 728–734. 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Br evaluations to best evaluate the most human lens nucleus with age: the basis for J Ophthalmol 91: 860–866. cost effective means of better treating presbyopia? Mol Vis 10: 956–963. Richdale K, Mitchell GL & Zadnik K (2006): presbyopia in the developing and Laviers HR, Omar F, Jecha H, Kassim G & Comparison of multifocal and monovision developed worlds. Gilbert C (2010): Presbyopic spectacle cov- soft contact lens corrections in patients with erage, willingness to pay for near correction, low-astigmatic presbyopia. Optom Vis Sci and the impact of correcting uncorrected 83: 266–273. Competing interests presbyopia in adults in Zanzibar, East Sherwin JC, Keeffe JE, Kuper H, Islam FM, Africa. Invest Ophthalmol Vis Sci 51: Muller A & Mathenge W (2008): Functional The authors report no conflict of 1234–1241. presbyopia in a rural Kenyan population: interest. The authors alone are respon- Leat SJ & Mohr A (2007): Accommodative the unmet presbyopic need. Clin Experiment sible for the content and writing of the response in pre-presbyopes with visual Ophthalmol 36: 245–251. paper. impairment and its clinical implications. Spierer A & Shalev B (2003): Presbyopia Invest Ophthalmol Vis Sci 48: 3888–3896. among normal individuals. Graefes Arch Lou MF (2003): Redox regulation in the lens. Clin Exp Ophthalmol 241: 101–105. Author Contributions Prog Retin Eye Res 22: 657–682. Strenk SA, Strenk LM & Koretz JF (2005): AD Goertz - acquisition of data. WC Lou MF & Dickerson JE Jr (1992): Protein- The mechanism of presbyopia. Prog Retin – Stewart - conception and design, inter- thiol mixed disulfides in human lens. Exp Eye Res 24: 379 393. Eye Res 55: 889–896. Takemoto L (1996): Increase in the intramo- pretation of data, drafting/revising the lecular disulfide bonding of alpha-A crystal- article, final approval. WR Burns - Lu Q, Congdon N, He X, Murthy GV, Yang A & He W (2011): Quality of life and near lin during aging of the human lens. Exp Eye revising the article. JA Stewart - con- – vision impairment due to functional presby- Res 63: 585 590. ception and design, revising the article, opia among rural Chinese adults. Invest Vincent JE (2006): Simple spectacles for adult final approval. LA Nelson - acquisition Ophthalmol Vis Sci 52: 4118–4123. refugees on the Thailand-Burma border. Optom Vis Sci 83: 803–810. of data, analysis of data, revising the Luo BP, Brown GC, Luo SC & Brown MM article. Weale RA (1962): Presbyopia. Br J Ophthal- (2008): The quality of life associated with mol 46: 660–668. presbyopia. Am J Ophthalmol 145: 618– 622. References Marmamula S, Keeffe JE & Rao GN (2011): Population-based cross-sectional study of Received on June 29th, 2013. American Optometric Association (2010): barriers to utilization of refraction services Accepted on October 6th, 2013. Care of the patient with presbyopia. St. in South India. BMJ Open 1: e000172. Louis: American Optometric Association. Maxwell WA, Waycaster CR, D’Souza AO, Correspondence: Barbero S (2013): An ancient explanation of Meissner BL & Hileman K (2008): A United William C. Stewart, MD presbyopia based on . Acta States cost-benefit comparison of an apod- 109 East 17th Street Ophthalmol, [Epub ahead of print]. ized, diffractive, presbyopia-correcting, mul- Suite 3407 Bekibele CO & Gureje O (2008): Impact of tifocal and a conventional Cheyenne self-reported visual impairment on quality of monofocal lens. J Cataract Refract Surg 34: Wyoming 82001 life in the Ibadan study of ageing. Br J 1855–1861. USA Ophthalmol 92: 612–615. McDonnell PJ, Lee P, Spritzer K, Lindblad Tel: 843-606-0776 Bron AJ, Vrensen GF, Koretz J, Maraini G & AS & Hays RD (2003): Associations of Fax: 888-808-9564 Harding JJ (2000): The ageing lens. Oph- presbyopia with vision-targeted health- Email: [email protected] thalmologica 214:86–104.

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