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Cover Stories | Mar 2006

The Mindset of Presbyopic Refractive Patients

Dispelling the myths of managing this patient group.

The mindset of the presbyopic refractive patient is unique and differs greatly from that of most pre-presbyopic refractive patients. Presbyopic patients no longer accept the loss of near vision as an unavoidable complication of growing older. Instead, older patients consider any loss of form or function as a sign of aging, something to be avoided at all costs. This mindset is particularly common among baby boomers, who, as a generation, associate aging with weakness. Evidence of this attitude abounds in forms such as medication for erectile dysfunction (a market that generated sales of $1.5 billion in 2005 and may exceed $6 billion by 2010) and hair transplants (increasing annually at a rate of 25%).1

The presbyopic baby boomer considers presbyopia and cataracts to be the defining moments of middle and old age, respectively. How many patients in their 50s or 60s have visited your office with cataracts and said, “I thought cataracts only happened to old people”? To help refractive surgeons manage these challenging patients, this article lays to rest several myths about presbyopes.

No. 1: Patients with monovision are truly happy.

In fact, presbyopes are never happy. They are the grumpiest, most demanding patients I know, and I speak from experience, as a presbyope myself. Although monovision may make these patients less unhappy, their distance vision is never as clear as when they had binocular distance vision, and their reading vision is never as good as it was with a decent pair of reading glasses. At best, monovision makes presbyopic patients slightly happier, but it never provides the vision that they truly want.

No. 2: Presbyopic low myopes are happy if their vision is corrected to plano.
This assumption is obviously false. Presbyopic low myopes will never forgive you for correcting them to plano. They do not always fully understand that they cannot put away their glasses after refractive surgery and that they can never regain the perfect reading vision they once had. As bad as correcting low myopic presbyopes to plano may be, however, the ultimate disaster is a hyperopic overcorrection in a patient who was previously a low myope. These people are extraordinarily unhappy, because their near point is even worse than it was previously with glasses. I therefore strongly recommend a contact lens trial before considering refractive surgery on any low myope who is entertaining the option of a full-distance correction.

No. 3: Presbyopic patients understand that, after refractive surgery, their reading vision will still worsen as they age.

When you correct presbyopic patients to plano and their reading vision worsens with age, they will blame you and regard their loss of vision as a complication of the surgery. They will also want an enhancement for better reading vision but will be unhappy with their loss of distance vision. Finally, despite the informed consent and however many hours spent discussing the issue with them, these patients will never fully agree that you explained this issue to them or that they understood prior to surgery that their reading vision would worsen as they grew older.

No. 4: The inadvertently undercorrected presbyopic patient will be happy with an enhancement to plano.

I frequently see patients who were inadvertently left slightly myopic following refractive surgery (eg, the -5.00D myope or the +3.00D hyperope who is left -0.50D). These patients will want to have their vision corrected to plano to improve their distance vision. They should always have a contact lens trial to see if they will truly be happy with a full distance correction, however. After an enhancement (despite your best efforts to warn them), they almost uniformly want to revert to the minimal undercorrection. Many of them do not understand how much they will miss the slight near vision they had before their enhancement.

No. 5: Conductive keratoplasty can provide blended vision, and the patient will not lose quality distance vision with the return of his near vision.

Although conductive keratoplasty (CK; Refractec, Inc., Irvine, CA) can be very useful, particularly for improving the near vision of hyperopic, astigmatic, multifocal IOL patients, the procedure almost always causes a loss of Snellen visual acuity or contrast sensitivity at distance and a loss of visual quality. I perform CK, but I always tell patients that it yields monovision, not blended vision.

No. 6: Presbyopic IOL patients will tolerate small refractive errors.

This idea is just wrong. Presbyopic IOL patients are incredibly sensitive to small refractive errors. If you are considering adding presbyopia-correcting IOLs to your surgical armamentarium, then you must, as a refractive cataract surgeon, use precise biometry and create astigmatically reproducible cataract incisions. In addition, you must be willing and able to treat postoperative refractive errors with a variety of different techniques, including the excimer laser (LASIK and PRK), limbal relaxing incisions, an IOL exchange, and possibly CK.


When managing presbyopes, it is important to address their most common concerns preoperatively. When I speak with patients regarding refractive IOLs particularly, I always mention that they may have a slight blur at distance, their reading distance may be fixed, and they might not have the full range of reading vision that they had previously. In addition, I explain that they may see ghost images and halos at night. Although these compromises may seem significant, most patients tolerate them very well and view them as a small price to pay for excellent near vision.

The best presbyopic refractive candidates are hyperopes, patients with cataracts who have had a loss of BCVA, individuals with greater than -4.00D of myopia who are accustomed to wearing bifocals or separate reading glasses, and patients who are willing to undergo enhancements for astigmatism or residual refractive errors. These are the patients to treat early in your learning curve with refractive cataract and excimer laser surgery. They are more likely than others to be happy with any improvement in their vision, because they had such poor visual quality originally.


Today, there are 90 million presbyopes in the US. The ultimate form of presbyopia is monofocal pseudophakia, and 3 million patients develop cataracts every year. The presbyopic refractive patient is the most demanding to visit our cataract and refractive practices on a daily basis. Nevertheless, those with successful visual outcomes whose expectations have been met are also the most grateful patients in our practices, and they represent an enormous opportunity for all of ophthalmology. 

Eric D. Donnenfeld, MD, is a partner in Ophthalmic Consultants of Long Island and Connecticut, and he is Co-Chairman of Corneal and External Disease at the Manhattan Eye, Ear, and Throat Hospital in New York. He is a consultant for Allergan, Inc.; Alcon Laboratories, Inc.; Advanced Medical Optics, Inc.; TLC Laser Eye Centers; and Bausch & Lomb, and he performs research for Alcon Laboratories, Inc.; Allergan, Inc.; and Santen, Inc. He acknowledged no financial interest in the products mentioned herein. Dr. Donnenfeld may be reached at (516) 766-2519; eddoph@aol.com.

1. American Society of Plastic Surgeons. Available at: http://www.plasticsurgery.org. Accessed: February 1, 2006.
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