Treatments for Presbyopia

Background: Accommodation is the eye’s ability to dynamically adjust its refractive power in order to focus images at varying distances sharply onto the retina. Presbyopia is the progressive deficit of accommodation that develops as an individual becomes older. An estimated 1.8 billion people worldwide have presbyopia.

Methods: This narrative review is based on pertinent publications retrieved by a PubMed search using the terms “presbyopia,” “presbyopic,” “intraocular lens,” “corneal inlay,” and “presbyLasik,” with particular attention given to prospective and retrospective studies, systematic reviews, and meta-analyses published in English or German up to February 2025. Additionally, clinical and surgical experiences from the Universitätsklinikum Frankfurt am Main (Germany) were taken into account.

Results: Many different techniques for the correction of presbyopia have been developed and studied, both nonsurgical and surgical. They differ from one another in invasiveness, the range of corrected vision, and expected optical and visual quality outcomes. Proper patient selection and precise preoperative diagnostic evaluation are prerequisites for success. The highest spectacle independence rate, of 96%, was achieved in a study with only 27 patients, in which multifocal intraocular lenses were implanted during cataract surgery or refractive lens exchange, with postoperative satisfaction exceeding 90%.

Conclusion: Presbyopia can be corrected by either nonsurgical or surgical means. However, the restoration of natural accommodation or a fully equivalent mechanism has not yet been achieved.

Cite this as: Kohnen T, Biller ML, Lwowski C, Böhm M, Kaiser KP: Treatments for presbyopia. Dtsch Arztebl Int 2025; 122: 501–7. DOI: 10.3238/arztebl.m2025.0094

Presbyopia results from the gradual, irreversible decrease in elasticity of the ocular lens as a person grows older. With worsening presbyopia, accommodation—the eye’s ability dynamically to adjust its refractive power—diminishes. Without accommodation, the eye cannot focus on objects at different distances from the beholder. Accommodation starts to decline in childhood, and by the age of 45–55 years the residual range of accommodation is approximately 1.5 diopters (D). Presbyopia, characterized by the loss of near vision, leads to lower quality of life and decreased autonomy, and for many of those affected it represents a functional and emotional burden (1). The German median age in 2023 was 44.6 years (German Federal Statistical Office), so around half the population can be estimated to have presbyopia. Around 1.8 billion worldwide are currently affected by presbyopia, and this figure is predicted to rise to 2.1 billion by 2030 (2, e1).

Presbyopia can be corrected using optical aids such as spectacles or contact lenses or by surgical treatment of the cornea or lens. Each method has its advantages and disadvantages. Figure 1 provides an overview of the various procedures for correction of presbyopia. Restoration of natural accommodation is not currently feasible.

Figure 1

Surgical and non-surgical treatments for presbyopia

If the aim is to eliminate dependence on spectacles, correction of presbyopia must be accompanied by compensation of defective distance vision, including short-sightedness (myopia), long-sightedness (hyperopia), and astigmatism. As a rule, this is accomplished in the course of the procedure selected. Functionally, the various treatments for presbyopia differ mainly in the zones of vision corrected. Three zones are distinguished: near vision (30–40 cm), intermediate vision (60–80 cm), and distance vision (> 1 m) (3). The term “target refraction” refers to the zone for which (ideally) a given procedure yields clear vision without further aids (Figure 2a). Several of the available procedures, e.g., a monofocal intraocular lens (IOL), correct the focus in only one zone of vision, while others, such as a multifocal IOL, correct more than one zone.

Figure 2

Schematic depiction of the different methods for non-surgical and surgical correction of presbyopia. The green line schematically reflects the light from close objects, the blue line, that from distant objects.

Methods

This narrative review is based on a survey of the literature in the PubMed database using the search terms “presbyopia,” “presbyopic,” “intraocular lens,” “corneal inlay,” and “presbyLasik.” We analyzed data from prospective and retrospective studies, systematic reviews, Cochrane reviews, and meta-analyses published in English or German up to February 2025, also taking account of the clinical and surgical experience at the Department of Ophthalmology of University Medical Center Frankfurt (Germany).

Non-surgical correction of presbyopia

Optical correction of presbyopia by means of spectacles or contact lenses is the most commonly chosen approach (Figure 2b). These devices are adaptable and reversible. Spectacles with progressive lenses enable clear vision at all distances, but it takes time to get used to them and some people never do (4). No studies direct comparing non-surgical and surgical procedures for correction of presbyopia have yet been published.

There are several established approaches to the correction of presbyopia with contact lenses. For instance, single-strength lenses can yield not only emmetropia, in which the eye images an object at an optically infinite distance in sharp focus on the retina, but also monovision (eBox 1). If monovision is achieved, there is usually no need for additional correction of near vision; however, this method is not suitable for all patients due to possible impairment of binocular vision. In monovision the dominant eye is naturally usually adapted for distance vision (emmetropia), the non-dominant eye for near vision (short sight/myopia). Furthermore, bifocal or multifocal contact lenses can be used. In contrast to spectacles with progressive lenses, these enable clear imaging, even of close objects, regardless of the direction of gaze (5). Bifocal contact lenses usually have a zone for distance vision (the upper half of the lens) and a zone for near vision (the lower half). In contrast, multifocal lenses usually have concentric rings on their anterior surface, each ring with a different refractive power (Figure 2c). The main reasons for discontinuing the use of multifocal contact lenses are visual acuity and comfort (6). In the event of poor hygiene, contact lenses may increase the risk of microbial keratitis, which can permanently damage vision in around 0.6 cases per 10 000 contact lens users (7).

eBox 1

Monovision

The drugs that can be used to correct presbyopia are listed in eBox 2. To date, however, these medications have hardly been employed in Germany.

eBox 2

Drug treatments for presbyopia

Surgical correction of presbyopia

Preoperative diagnostic evaluation and patient selection

Close examination of the medical history and detailed diagnostic evaluation before any surgery are crucial if optimal correction of presbyopia is to be achieved. The inclusion and exclusion criteria of the various surgical options must be respected and the decision taken on an individual basis. Questioning about the history should cover not only medical aspects, but also private, occupational, and non-medical factors. The patients’ daily routine should be discussed, as well as their expectations, views, and wishes. The ophthalmologist conducting the discussion should not confine him- or herself to the ocular history, but also establish the medical history in general, because some internal diseases (e.g., diabetes mellitus) can damage the eyes.

A selection of the most commonly used means of preoperative assessment, instrument-based and otherwise, can be found in eBox 3. All of these examinations should be conducted by trained staff.

eBox 3

Preoperative examinations in patients with presbyopia (selection)

Laser-assisted corneal surgery

Dynamic adjustment of the refractive power of the eyes (accommodation) results from a change in the shape of the ocular lens; the refractive strength of the cornea remains unaltered. Cornea-based procedures can therefore improve near visual acuity only by means of monovision or enhanced depth of focus.

Laser-induced monovision

Several different keratorefractive procedures can be used to correct presbyopia by establishing monovision (eBox 1). These include laser in-situ keratomileusis (LASIK), keratorefractive lenticule extraction (KLEx), and photorefractive keratectomy (PRK), each in various subtypes. The complication rates are mostly low (8). For LASIK the rate is below 0.7%, embracing flap problems, epithelial defects, and inflammations, as well as epithelial ingrowth and debris under the flap. The risk of microbial keratitis after LASIK (5 in 10 000) is comparable with that associated with wearing contact lenses for a year (1 to 17 in 10 000) (9).

Studies have shown that around 90% of patients are satisfied with the result of laser surgery to induce monovision. As a rule, the procedure achieves good functional near vision and excellent distance vision (10, 11). As with induction of monovision by means of contact lenses, there are disadvantages: impaired vision in the intermediate zone, poorer visual acuity in the dark, decreased contrast sensitivity, and reduced spatial perception (11).

Multifocal excimer laser corneal ablation

The concept of corneal ablation with the excimer laser was first developed in the early 1990s and later optimized (e2). The laser is used to reshape the cornea with concentric or blended zones of different refractive powers, creating focal areas for near, intermediate, and distance vision (Figure 2d). Surface profiles for this purpose are marketed by various manufacturers under different names (e.g., PresbyLASIK and PresbyMAX)(12–14). The clinical results of multifocal excimer corneal ablation, together with its advantages and disadvantages, are shown in the Table.

Table

Treatments for presbyopia (results expressed as percentage or mean ± standard deviation)

Intracorneal inlays

Corneal inlays have been used for some years. Different techniques follow different optical principles. The inlays are implanted in a previously prepared corneal pocket in the non-dominant eye (15). Should there be complications, fluctuations in refraction, or poor tolerance of the implant by the patient, the inlays can therefore be removed with relatively low investment of time and effort. Moshifar et al. reported that surgical intervention was necessary in 12% of patients with intracorneal inlays. The procedures included explantation (8%), additional refractive surgery, repositioning, and lamellar irrigation (16).

Lens surgery

Presbyopia can be corrected in various ways with the aid of IOL. These are usually inserted into the capsular bag after removal of the natural crystalline lens. The IOL is implanted either as part of a cataract operation or, if there is no clinically meaningful opacity of the natural lens, in the course of refractive lens exchange (RLE). Nowadays artificial lenses are predominantly made using foldable hydrophobic acrylates, enabling reduction of incision size to less than 2.5 mm.

The International Organization for Standardization (ISO 11979–7, 2024) defines four main categories of artificial lenses: monofocal, toric, presbyopia-correcting (also known as simultaneous vision range lenses), and accommodative IOL.

Monofocal intraocular lenses

In an eye with normal vision, monofocal IOL (so-called single-strength lenses) produce a clearly focused, well contrasted image of an object at optical infinity (distance), but a blurred, low-contrast image in the near and intermediate zones. Accordingly, monofocal IOL focus on a single point, which can be selected as the “refractive goal” preoperatively (= target refraction). The rate of complete spectacle independence in cataract surgery using monofocal IOL with the aim of bilateral emmetropia is known to be low (5%) (17). Monofocal IOL can also be used to establish monovision, enabling additional correction of presbyopia or near visual acuity with the limitations mentioned above (18).

The majority of monofocal lenses implanted are the inexpensive spherical type. These produce positive spherical aberrations, which can affect the quality of vision. Spherical aberrations are imaging phenomena in which light passing through the center of a spherical object are refracted less strongly that at the periphery of the object (eBox 4). These classical spherical IOL are now accompanied by aspherical designs of artificial lens that compensate such imaging errors by means of a specifically optimized surface curvature (19, 20). In this way the visual impression and contrast sensitivity at night can be improved, especially in younger patients, who tend to have larger pupils (21, 22). If there is corneal irregularity (astigmatism), it can be corrected with toric artificial lenses. The cylinder axis must either be marked preoperatively or identified by means of digital systems during the procedure (Figure 3).

Figure 3

Digital systems assist the intraoperative rotation of an intraocular lens

eBox 4

Spherical aberrations

Intraocular lenses with extended depth of focus

Extended depth of focus lenses (EDoF-IOL) take advantage of a technological advance permitting enlargement of the focal range. Compared with a monofocal lens, the distant focus is extended proximally, so that the EDoF-IOL user can see clearly not only at distance but also in the intermediate zone of vision and sometimes even in the near zone (23, 24). The aim is to achieve functional near vision, so that large lettering can be recognized without spectacles, while the reading glasses needed for smaller fonts will usually be of low strength (around + 1 D).

Different EDoF-IOL work on different optical principles.

Pinhole IOL function according to the stenopeic principle: the small hole reduces peripheral rays (spherical aberrations), decreases the area of scatter on the retina, and increase the depth of focus (Figure 2e). The disadvantages of pinhole IOL are particularly the difficulty of viewing the posterior chamber and the reduced amount of light penetrating the eye, which may impair vision in conditions of low light (25).

Diffractive EDoF-IOL take advantage of an optical–physical principle similar to that with multifocal artificial lenses. They have a distant focus and one in the intermediate zone. They differ from bifocal artificial lenses—the use of which has now been almost completely discontinued—in that the two foci are so close to one another that they practically merge. A disadvantage of diffractive optics is the occurrence of adverse optical effects (e.g., halo and glare) (26).

Non-diffractive aspherical IOL have already been mentioned in the section on monofocal IOL above. Through the intentional induction of negative spherical aberrations (eBox 4), they produce an extended range of focus in the near zone. A special type of these lenses is the wavefront-modulating non-diffractive EDoF-IOL (Figure 4b). This design minimizes optical phenomena and improves near and especially intermediate visual acuity compared with monofocal IOL (Table, eTable) (27, 28).

Figure 4

Split-lamp images of different types of intraocular lenses

eTable

Overview of studies on various types of lenses (results expressed as mean with standard deviation)

Multifocal intraocular lenses

Multifocal intraocular lenses (MIOL), in use since the 1980s, are the only type of artificial lens that gives patients good vision at all distances without visual aids (eTable 1) (e3, e4, e5). The simultaneous imaging of various objects at different distances leads to image overlay and thus to reduction in quality of vision in the shape of reduced contrast sensitivity (particularly with wide pupils and at night) and to optical phenomena such as glare and halos around light sources. This means that the patient has to be prepared to compromise and accept these drawbacks (29, 30, 31, 32). As a rule, neuroadaptation results in the user being less disturbed by the optical phenomena after a certain time (33). If the phenomena are extremely disturbing and no neuroadaptation occurs, an experienced surgeon can exchange the MIOL for a model with different optics (34).

A higher rate of spectacle independence is attained with MIOL than with monovision: 71% versus 26% of patients, respectively, no longer need to wear spectacles at all (odds ratio 7.51; 95% confidence interval [3.89; 14.47]; P < 0.01) (35). However, more patients with MIOL report optical phenomena, above all glare (79% against 56% of those with monovision, P < 0.01) (36). In a study by Kohnen et al., MIOL implantation achieved spectacle independence in 96% of patients (37).

MIOL are differentiated according to their optical principles:

Refractive MIOL have two or more ring-shaped spherical zones with different foci, including one for close objects. They offer patients good distance vision with variable intermediate to near visual acuity (38). In comparison with diffractive MIOL, refractive MIOL depend more strongly on optimal centering and on pupil diameter.

Diffractive MIOL typically possess a spherical refractive anterior surface and a diffractively acting posterior surface (Figure 2c). These bundle the incident light onto three or four foci (trifocal or quadrifocal) (29, e6). For reasons of physics, a slightly higher portion of light is lost to scatter (36). The trifocal effect is more highly dependent on pupil diameter and centering (30). Diffractive trifocal MIOL enable spectacle independence to a considerable degree and are, despite the aforementioned minor optical phenomena, associated with very high patient satisfaction (Table, eTable) (37, 39).

Alternative procedures and perspective

In addition to the interventions described here, further treatments such as scleral implants, pharmacotherapy, electrostimulation, and IOL that actually offer accommodation are being enhanced and tested (e7).

Furthermore, a refinement of the current femtosecond laser offers the potential for correction of presbyopia by altering the density of corneal collagen fibrils in order to change the cornea’s refractive index. This is referred to as refractive index shaping (RIS) or laser-induced refractive index change/customization (LIRIC). To date, only animal studies have reported the successful application of this technique (40). Until this new method becomes widely used in some years’ time, presbyopia will continue to be corrected by compensation with spectacles and contact lenses or by lens surgery. It remains to be seen how the currently established procedures with various artificial lenses will be expanded or rendered obsolete by new treatments.

Research funding

This article was not supported by research funding.

Conflict of interest statement

TK: Consultant, research funding recipient, and speaker for Alcon, Oculus, Schwind, Staar; consultant and speaker for Tarsus, Ziemer; research funding recipient and speaker for Teleon Surgical; consultant for Abbvie, Geuder, LensGen, Santen, Stadapharm, Thieme, Zeiss Meditec; speaker for Allergan, Bausch & Lomb, Johnson & Johnson, MedUpdate, streamedup.

KPK: Lecture fees received from Oculus.
The remaining authors declare that no conflict of interest exists.

Manuscript received on 11 September 2024, revised version accepted on 19 May 2025

Translated from the original German by David Roseveare

Corresponding author
Univ.-Prof. Dr. med. Thomas Kohnen

Information on CME

This article has been certified by the North Rhine Academy for Continuing Medical Education. The questions on this article may be found (in German) at http://daebl.de/RY95 (Deutsches Ärzteblatt’s CME portal). Their English translation may be found in the PDF version of this article. The closing date for entries is September 4, 2026. Participation is possible at cme.aerztebatt.de

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