Ophthalmic & Physiological Optics ISSN 0275-5408
EDITORIAL
Presbyopia: physiology, prevention and pathways to
correction
Presbyopia is a ubiquitous, global problem. Indeed, it is
estimated that over a billion adults worldwide are currently
affected by presbyopia1 with many uncorrected or under-
corrected.2 Significantly for clinicians, this figure is only set
to rise, given that 40% of the global population is expected
to be over 40 years of age by 2030.3 There is, therefore, a
tangible and pressing need to understand the pathogenesis
of presbyopia and to develop innovative technology to
ameliorate its effects on the individual and the world econ-
omy.4 We are, therefore, delighted that Ophthalmic & Phys-
iological Optics has dedicated a Feature Issue to this topic,
which we hope will be of interest to clinicians and research-
ers alike. Reflecting the multidisciplinary nature of presby-
opia research, the original articles in this Feature Issue
cover a broad base from basic science to clinical research,
and on topics from clinical measurement of ocular accom-
modation to understanding the impact of presbyopic cor-
rections on gait.
Ever since the early pioneering work of Donders5 and
Duane,6 it is now universally accepted that the eyes subjec-
tive amplitude of accommodation declines with age. From
as early as childhood, the amplitude of this dynamic,
biomechanical process reduces, ultimately leading to symp-
toms of asthenopia and blurred vision in mid-life.7 How-
ever, subjective responses to near stimuli alone do not
elucidate the role of depth-of-focus on the resultant ampli-
tude of accommodation. By extending the work of others,8
therefore, the first paper in this Feature Issue9 tackles this
problem by comparing amplitude of accommodation mea-
sures obtained using dynamic retinoscopy with two subjec-
tive methods. As expected, their data suggest that objective
measurements of amplitude of accommodation are signifi-
cantly lower than subjective findings, which is most likely
due, at least in part, to the eyes depth-of-focus. The
authors also present normative amplitude of accommoda-
tion ranges for individuals from 5 to 60 years of age, which
will be of relevance to the practicing clinician.
Notwithstanding a century of study, the precise mecha-
nism of ocular accommodation remains a topic of
debate.10, 11 In the young human eye, the majority of mea-
sured changes in vivo have shown that, in a response to cil-
iary muscle contraction,12 crystalline lens thickness
increases,13 lens diameter decreases,14 and both the anterior
and posterior curvature of the lens increase.15 With age, the
primary correlate of presbyopia appear to be change in the
viscoelastic properties and stiffening of the crystalline
2015 The Authors Ophthalmic & Physiological Optics 2015 The College of Optometrists
Ophthalmic & Physiological Optics 36 (2016) 14
lens.16 The next two papers in the Feature Issue explore the
accommodation mechanism further by examining the role
of zonular fibres and their putative contribution to presby-
opia. Flugel-Koch and colleagues17 describe an anteriorly
located system of zonular fibres that they propose could be
involved in fine-tuning the accommodation response by
conveying forces from intrinsically-innervated sections of
the ciliary muscle to the crystalline lens. In addition, Croft
et al.18 examine, in both human and rhesus monkey eyes,
the dynamic accommodative movements of the lens cap-
sule, posterior lens, and the strand that attaches to the pos-
terior vitreous zonule insertion zone and posterior lens
equator, for which the authors use the abbreviation PVZ
INS-LE. Using ultrasound biomicroscopy, the authors con-
clude that the PVZ INS-LE may act as a strut to the poste-
rior lens equator, thus facilitating accommodative forward
lens equatorial movement and lens thickening. Their data
also show age-related changes in these morphometric
parameters, which they suggest should be considered in
future therapies to correct presbyopia. Although the lens
may be the primary optical reason for presbyopia, Croft
et al.18 demonstrate that it is not the only player and this is
further evidenced by the poor performance of accommo-
dating IOLs to date. The next paper in the Feature Issue
observes ocular biometric changes over a 2.5 year longitu-
dinal period in human participants aged 3441 years, to
determine the influence of age-related ocular structural
changes on the accommodative response prior to the onset
of presbyopia. Laughton et al.19 conclude that the accom-
modative decrease in anterior chamber depth and increase
in lens thickness and axial length significantly attenuate
with age; however, the response per dioptre of accommoda-
tion exerted remains constant with age. These findings fur-
ther support the hypothesis that an increase in lenticular
stiffness is likely to be primarily responsible for the onset of
presbyopia.
Of particular interest to the manifest presbyope is the
advent of new devices and techniques purporting to restore
ocular accommodation to the ageing eye.20 Despite signifi-
cant effort and attention, however, these approaches have,
in general, failed to achieve their desired goal.21 Here, Atch-
ison and co-workers22 ask whether the use of small-aper-
ture corneal inlays or contact lenses as presbyopic
corrections might influence the patients visual field. Using
both a theoretical and an empirical approach, the authors
conclude that annular stops (e.g. KAMRA inlays), unlike
1
Editorial
circular artificial pupils, have only minor effects on mea-
surements of the visual field. In their paper, de Jong et al.23
ask whether post-cataract surgery ocular wavefront aberra- 3.
tions of eyes with aspheric intraocular lenses can be
predicted from preoperative measures of corneal shape and 4.
other eye characteristics. Based on data from 60 eyes of 60
participants, the authors conclude that defocus, astigma-
tism, vertical coma and spherical aberration terms are all
5.
associated with corneal shape in pseudophakic eyes. Modi-
fying these terms might inform and enable future IOL cus-
tomisation.
6.
Finally, a paper by Elliott et al.24 adopts a more holistic
approach to presbyopia correction and considers the
impact of spectacle lens correction on safe ambulation.
Specifically, the study measures stair ascent and descent tri- 7.
als in 14 healthy long-term multifocal spectacle wearers
whilst wearing intermediate and full addition bifocals and
progressive addition lenses (PAL), and single-vision dis- 8.
tance spectacles. The authors conclude that intermediate
PALs provide safe gait parameters and good short-term
reading, and that the use of these devices might help to 9.
reduce falls in older well-adapted full addition PAL
wearers.
In summary, the original papers presented in this Fea- 10.
ture Issue of Ophthalmic & Physiological Optics provide
a contemporary snapshot of the varied research con-
ducted in this challenging and important area of vision
science. We very much thank the cohort of anonymous 11.
reviewers for their help and assistance in compiling this
Feature Issue. We hope that the papers presented herein
will stimulate debate and ideas for future research that
12.
will ultimately lead to the restoration of accommodation
to the ageing eye.
Leon N. Davies1, Mary Ann Croft2, Eric Papas3 13.
and W Neil Charman4
1
Ophthalmic Research Group, Life and Health Sciences,
Aston University, Birmingham, UK,
2 14.
Department of Ophthalmology and Visual Sciences,
University of Wisconsin Clinical Sciences Center, Madison,
USA,
3 accommodation. Invest Ophthalmol Vis Sci 2011; 52: 3689
School of Optometry and Vision Science, University of
New South Wales, Sydney, Australia
15.
and 4University of Manchester, Manchester, UK
E-mail address: l.n.davies@aston.ac.uk
16.
References
1. Holden BA, Fricke TR, Ho SM et al. Global vision impair- 17.
ment due to uncorrected presbyopia. Arch Ophthalmol
2008; 126: 17311739.
2. Goertz AD, Stewaert WC, Burns WR, Stewart JA & Nelson 18.
LA. Review of the impact of presbyopia on quality of life in
2 2015 The Authors Ophthalmic & Physiological Optics 2015 The College of Optometrists
the developing and developed world. Acta Ophthalmol 2014;
92: 497500.
United States Census Bureau www.census.gov, accessed
November 2015.
Frick KD, Joy SM, Wilson DA, Naidoo KS & Holden BA.
The global burden of potential productivity loss from
uncorrected presbyopia. Ophthalmology 2015; 122: 1706
1710.
Donders FC. On the Anomalies of Accommodation and
Refraction of the Eye, The New Sydenham Society: London,
1864.
Duane A. An attempt to determine the normal range of
accommodation at various ages, being a revision of Don-
ders experiments. Trans Am Ophthalmol Soc 1908; 11: 634
641.
Pointer JS. The presbyopic add. II. Age-related trend and a
gender difference. Ophthalmic Physiol Opt 1995; 15: 241
248.
Anderson HA & Stuebing KK. Subjective versus objective
accommodative amplitude: preschool to presbyopia. Optom
Vis Sci 2014; 91: 12901301.
Leon A, Estrada JM & Rosenfield M. Age and the amplitude
of accommodation measured using dynamic retinoscopy.
Ophthalmic Physiol Opt 2016; 36: 512.
Richdale K, Sinnott LT, Bullimore MA et al. Quantification
of age-related and per diopter accommodative changes of
the lens and ciliary muscle in the emmetropic human eye.
Invest Ophthalmol Vis Sci 2013; 54: 10951105.
Schachar RA. Human accommodative ciliary muscle config-
uration changes are consistent with Schachars mechanism
of accommodation. Invest Ophthalmol Vis Sci 2015; 56:
6075.
Sheppard AL & Davies LN. In vivo analysis of ciliary muscle
morphologic changes with accommodation and axial ame-
tropia. Invest Ophthalmol Vis Sci 2010; 51: 68826889.
Kasthurirangan S, Markwell EL, Atchison DA & Pope JM.
MRI study of the changes in crystalline lens shape
with accommodation and aging in humans. J Vis 2011; 11:
19.
Sheppard AL, Evans CJ, Singh KD, Wolffsohn JS, Dunne
MCM & Davies LN. Three-dimensional magnetic reso-
nance imaging of the phakic crystalline lens during
3697.
Rosales P, Dubbelman M, Marcos S & van der Heijde R.
Crystalline lens radii of curvature from Purkinje and
Scheimpflug imaging. J Vis 2006; 6: 10571067.
Heys KR, Cram SL & Truscott RJ. Massive increase in the
stiffness of the human lens nucleus with age: the basis for
presbyopia? Mol Vis 2004; 10: 956963.
ugel-Koch C, Croft MA, Kaufman PL & L
Fl utjen-Drecoll E.
Anteriorly located zonular fibres as a tool for fine regulation
in accommodation. Ophthalmic Physiol Opt 2016; 36: 1320.
Croft MA, Heatley G, McDonald JP, Katz A & Kaufman PL.
Accommodative movements of the lens/capsule and the
Ophthalmic & Physiological Optics 36 (2016) 14
 Editorial

strand that extends between the posterior vitreous
zonule insertion zone & the lens equator, in relation to the
vitreous face and aging. Ophthalmic Physiol Opt 2016; 36:
2132.
19. Laughton DS, Sheppard AL & Davies LN. A longitudi-
nal study of accommodative changes in biometry during
incipient presbyopia. Ophthalmic Physiol Opt 2016; 36: 33
42.
20. Charman WN. Developments in the correction of presby-
opia II: surgical approaches. Ophthalmic Physiol Opt 2014;
34: 397426.
21. Ong HS, Evans JR & Allan BDS. Accommodative intraocular
lens versus standard monofocal intraocular lens implanta-
tion in cataract surgery. Cochrane Database Syst Rev 2014; 5:
CD009667.
22. Atchison DA, Blazaki S, Suheimat M, Plainis S & Charman
WN. Do small-aperture presbyopic corrections influence the
visual field? Ophthalmic Physiol Opt 2016; 36: 5159.
23. de Jong T, Canovas C, Weeber H & Jansonius NM. From
corneal shape to ocular wavefront in eyes with aspheric
IOLs: the feasibility of IOL customisation. Ophthalmic Phys-
iol Opt 2016; 36: 4350.
24. Elliott DB, Hotchkiss J, Scally AJ, Foster R & Buckley JG.
Intermediate addition multifocals provide safe stair ambula-
tion with adequate short-term reading. Ophthalmic Physiol
Opt 2016; 36: 6068.

Leon N. Davies. Leon is Director of Research and a Reader in Optometry &

Physiological Optics at Aston University. He undertook both his under-
graduate optometry degree and PhD at Aston University, and joined their
academic staff in 2005. Leon is a past Clinical Editor of Optometry Today
and currently sits on the Editorial Boards of BioMed Research International
and the CET journal Optometry in Practice. In recognition of his research,
Leon was awarded the inaugural College of Optometrists Research Fellow-
ship Award for a study examining in vivo 3-D Magnetic Resonance Imaging
of crystalline lens morphology in phakic eyes during accommodation, and
the inaugural Neil Charman Medal for research in optometry, optics and
vision science. He holds Fellowships with the College of Optometrists, the
American Academy of Optometry and a Senior Fellowship with the Higher
Education Academy.

Mary Ann Croft. Mary Ann obtained an MS degree in veterinary science in

1986 and joined the Paul L. Kaufman team in 1988, where she worked in
the fields of aqueous dynamics, accommodation and presbyopia. She is now
a Distinguished Researcher at the University of Wisconsin Madison,
Department of Ophthalmology and Visual Sciences. Her work has utilized
contrast agents, surgical procedures and advanced imaging techniques (en-
doscopy, Scheimpflug and goniovideography, and ultrasound biomi-
croscopy, UBM) in the rhesus monkey and human to contribute significant
new information relevant to accommodation and presbyopia pathophysiol-
ogy. She reviews for several prominent ophthalmological journals, and her
memberships include Association for Research in Vision and Ophthal-
mology, Chevalier and Governing Committee Member of the Accommoda-
tion Club, and the International Society of Presbyopia.

2015 The Authors Ophthalmic & Physiological Optics 2015 The College of Optometrists 3
Ophthalmic & Physiological Optics 36 (2016) 14
Editorial

Eric Papas. Eric is Professorial Visiting Fellow at the School of Optometry

and Vision Science, University of New South Wales, Sydney, Australia. He
holds degrees in physics from the University of Birmingham, UK; optome-
try from the University of Manchester, UK and a doctorate from the
University of New South Wales, Australia. Formerly Executive Director of
Research and Development at the Brien Holden Vision Institute and Vision
CRC, he has worked with all the major companies in the contact lens field
and has made significant contributions to the development of several con-
tact lenses, including a number of multifocals, as well as lens care products.
He recently received the Max Schapero Award from the American Academy
of Optometry in recognition of his contributions to the field. He serves as
Associate Editor for Contact Lens & Anterior Eye, Associate Topical Editor
for Optometry & Vision Science and sits on the editorial board of both Clini-
cal & Experimental Optometry and Eye & Contact Lens.

W Neil Charman. Emeritus Professor Neil Charman worked for many years
in the Optometry Department of the University of Manchester Institute of
Science and Technology. He has a long-term interest in various aspects of
visual optics, originally focusing mainly on ocular aberration and accom-
modation but, with advancing years, moving on to include presbyopia and
its correction. He is a co-editor, with Ionnis Pallikaris and Sotiris Plainis, of
the recent book Presbyopia: Origins, Effects and Treatment. Neil was the
founding Editor of Ophthalmic & Physiological Optics and received the
Charles F Prentice Award from the American Academy of Optometry in
2005 in recognition of his major contributions to research in visual and
physiological optics. For his work on behalf of the optometric profession,
Neil was made an Honorary Fellow of the College of Optometrists.

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Ophthalmic & Physiological Optics 36 (2016) 14