10 year old patient complains of distance blur at school.  When you ask a few more questions, they also state that sometimes when they are reading they have headaches or blurry vision.  Sometimes they even tell you that their distance vision is blurry after they read (though it is rare for a young child to be this perceptive).  

When vision is checked, acuity is typically 20/25 to 20/40 unaided.  Usually worse at distance than near, but they read the 20/20 line really slowly up close.  Their ending prescription is anywhere from +0.50 (low hyperopia or far sightedness) to -0.50 (low myopia or near sightedness), but the 20/20 line is still hard for them to read.  Note: I know ODs out there know what I mean when I say myopia or hyperopia, but I am including the other terms for all other readers to the blog!

Kids and the phoropter: not exactly a match made in heaven.  Best to  not confuse things too much with subjective testing that is difficult to understand (like phorias or fused cross cylinder).

Then you switch to near testing.  Depending on the patient, only certain tests yield good results.  Cover test is normal (most kids don't do well with phorias and vergences!).  You might be able to get a binocular fused cross cylinder on older children if you are lucky. The responses vary. My two best tests are NRA/PRA and near retinoscopy (such as MEM).   Classic NRA/PRA readings are low usually on both plus and minus blur points.  They typically do very poorly with PRA (the minus blur points).  You can of course also do an accommodative facility test (with the +2.00/-2.00 flippers and a timer), but in the real world this test is very time consuming to perform in a routine exam.

Near Retinoscopy: I should do it more that I do -- lots of great information can be gleaned.   But I don't have these cards in every exam room, so I typically rely on NRA/PRA results and then trialing loose lenses at near subjectively.

Then I like to demonstrate with loose lenses to the patient. Get them out of the phoropter as soon as possible!  Let them hold a near card or reading material.  Hold up a +0.75 lens and see their response.  It is usually quite dramatic.  Now sometimes the kid just wants glasses, so hold up a -0.75 or -1.00 and see what happens.  If they are really having accommodative issues, they aren't going to like this at all.  I will often show the patient what happens when they switch from near to distance with the lens to demonstrate that the glasses are only good for up close.

Prescription wise, I typically Rx +0.75 to +1.25 depending on the patient's distance prescription.  The hardest part in all of this, of course, is telling the patient's parents why they need glasses.  I always talk about Vision Therapy as an option too, but in my area, it is very expensive and of course not covered by insurances.  I always explain that the glasses are for reading only (any near activity they are going to perform for longer than 10 minutes).  A near activity I define as anything they are holding closer than arm's length.  That means they are going to have to take the glasses on and off at school, but believe me this goes over much better than telling them they need bifocals.  Here is my general discussion:

I hope this helps.  Telling a parent their child needs glasses is difficult in any situation, but when you tell them they need glasses for near when they have been complaining to mom and dad for months their distance vision is blurry, it is even harder.  Most parents only know myopia (or near sightedness), so any other use of glasses seems strange.  Again, especially when their child is coming home complaining of distance blur!  I always like to tell parents that studies have shown myopia can be related to eyes being over-strained at near, so hopefully the use of these glasses can help with delaying myopia onset.  If the parent is near sighted, they will appreciate any efforts to prevent their child from having a large myopic prescription.  In a future post I will detail a patient's guide to accommodative dysfunction to hopefully make things easier for parents to understand!  

Then a little thing called 40 happened.

Believe me, for the people out there with perfect vision (known as emmetropia by the way), the development of presbyopia is a truly terrible occurrence.  All of a sudden, they can't see to do the things they used to do so easily.  Reading, computer use, using the cell phone.  All of it is blurry. When they try to do any of these activities for extended periods of time, they get horrible headaches and feelings of eye strain. And the closer they bring things, the blurrier it gets!  At first holding things away helped, but then it's like their arms just aren't long enough anymore.  It is a horrible, horrible visual disaster.

If you or someone you know is suffering from these symptoms, and they are around the age forty mark, they are likely experiencing the effects of presbyopia.  Presbyopia is the natural decrease in the visual focusing system's ability to clear near images.  It happens to every single person at some point in time; some people are affected younger and some people aren't affected until their later 40s. What exactly is happening, though, to cause this change?

Your focusing system is comprised of the lens and the muscles (the ciliary muscles to be precise) that help move the lens to adjust its focus.  Remember from earlier posts about cataracts, the lens is one of those few structures in the body that never stops growing.  It lays down layer after layer every year, making the structure thicker and harder for your eye muscles to adjust.  When the lens gets too thick to clearly focus near images without substantial strain on your focusing system, then we have reached the point of presbyopia.  I always like to reassure my patients that this is a change that everyone is going to go through eventually, and it is happening gradually over time (even though in most cases it feels like it happens over night!).  

How do we fix presbyopia?  Just like any other refractive error (to many of my patient's grief that have never needed them before), the solution is glasses or contact lenses.  Some patients can just use reading glasses for fine print or computer use, and then remove them for any distance activities.  Patients that also have a distance refractive error (like hyperopia, myopia, or astigmatism) will need bifocal (lined) or progressive (no line) glasses to correct for all ranges of vision.  Multifocal contact lenses are also an option for some patients, but do keep in mind that vision won't be as clear at all ranges with multifocal contact lenses as they are with glasses.  Many patients can get good results for most ranges, but contact lenses don't work for everyone.  

Just remember, presbyopia is a difficult time --especially for those of us that have never worn glasses before! Eye care providers have tons of experience prescribing glasses for this change because every single person eventually goes through it.  It may seem very trying at first if this is your first time wearing glasses or contact lenses, but with the appropriate prescription you will be seeing clearly again to do all of the reading and computer activities you enjoy.