Presbyopia after 45:
glasses, lenses or laser?

Around age 45, something inevitable happens: the restaurant menu becomes unreadable. The phone gradually moves further from the face. The small print on medications becomes a problem. This is presbyopia, and it affects 100% of the population.

In over 25,000 procedures, I have met thousands of presbyopic patients. The question is always the same: can I free myself from reading glasses? The honest answer is: it depends on what you are willing to accept in return — and above all, which solution you choose.

The problem: three distances, not two

The young lens focuses at all distances continuously — from infinity down to a few centimetres. This ability is called accommodation, and after 40-45 it is progressively lost as the lens becomes increasingly rigid. At 45, residual accommodation is approximately 3 dioptres. At 55, it drops below 1.5. At 65, it is virtually zero. The process is continuous and irreversible.

It is crucial that daily vision requires three distances, not two: distance vision (driving, cinema, landscape), intermediate vision (computer, dashboard, person at 60-80 cm) and near vision (phone, reading, labels at 30-40 cm). The presbyopic lens can no longer "zoom" between these three distances. Any solution — glasses, lenses, laser or surgery — must work with this triple requirement.

Non-surgical options

Reading glasses and progressives

The simplest and risk-free solution. A pair of +1.50 / +2.00 glasses corrects near vision but blurs distance and intermediate. Progressive lenses cover all three distances in a single lens, but require adaptation, have a restricted useful field of view in lateral zones, and cost CHF 500-1,500. Every 2-3 years, a stronger prescription is needed.

Multifocal contact lenses

Modern multifocal contact lenses organise concentric zones for distance, intermediate and near vision. The brain selects the sharpest image depending on the distance. They work well for many people, but visual quality is slightly lower than progressive lenses — the optical compromise is inevitable when compressing three focal points on the same pupil. Cost: CHF 400-800/year.

Intraocular surgical options

Multifocal intraocular lenses — refractive and diffractive

When the patient has a cataract — an opacified lens — its replacement with a multifocal artificial lens is the logical solution: cataract and presbyopia are resolved in the same procedure. Multifocal lenses fall into two broad families.

The refractive lenses use concentric zones with different curvatures to focus light at multiple distances. Diffractive lenses use microscopic rings on the optical surface that diffract light, creating simultaneous focal points for each distance. The most recent are trifocal lenses, which dedicate three distinct focal points to distance, intermediate (60-80 cm) and near (30-40 cm). Clinical results are documented and generally satisfactory, but a percentage of patients report night halos, reduced contrast sensitivity and glare phenomena — intrinsic effects of the multifocal principle that divides light into multiple focal points.

Laser for presbyopia: corneal correction

Laser correction of presbyopia works on the cornea — the outer surface of the eye — to create a multifocal profile that increases depth of field. The fundamental advantage: the lens remains intact, the eye is not opened, there is no entry into the globe.

Monovision: the basic principle, possible with any laser

The monovision is the simplest concept: the dominant eye is corrected for distance and the non-dominant eye for near (typically -1.00 / -2.00 D). The brain learns to select the right image. It can be achieved with any laser platform — LASIK, PRK, TransPRK, and also SMILE — as it does not require a specific ablation profile: simply aim for different refractions for each eye.

The limitation of pure monovision: it partially sacrifices stereoscopy, leaves the intermediate distance uncovered, and approximately 15% of patients do not adapt. This is why, before any procedure, a contact lens trial of 2-3 weeks is mandatory.

PresbyLASIK: the specific multifocal profiles

Technological evolution has produced dedicated ablation profiles that go beyond simple monovision. All now use a hybrid approach: a micro-monovision component combined with multifocal corneal remodelling. The result is corneal multifocality covering three distances with less compromise on stereoscopy. Three profiles dominate the global clinical landscape.

Supracor (Technolas / Bausch+Lomb)

Supracor creates an additional paracentral ablation that generates an intermediate-near zone, while the periphery corrects distance. Both eyes are targeted at -0.50 D residual myopia — the lowest anisometropia among all profiles. The increase in positive spherical aberration widens the depth of field. Initially developed for hyperopic presbyopes, it has produced documented results: binocular distance acuity ≥20/25 in 100% and near J1.5 in 90% at 24 months.

Presbyond LBV (Carl Zeiss Meditec)

Presbyond — Laser Blended Vision — combines micro-monovision (non-dominant eye targeted at approximately -1.50 D) with controlled induction of negative spherical aberration via proprietary non-linear aspheric profiles. This creates a "blend zone" between the two eyes: each eye has an extended depth of field, and the two zones overlap covering the intermediate distance. The brain perceives a smaller difference between the eyes compared to classic monovision. Works on myopes, hyperopes and emmetropes. Requires the Zeiss MEL 90 laser.

PresbyMAX (SCHWIND) — our choice

PresbyMAX, developed by Prof. Jorge Alió and perfected by SCHWIND, creates a central bi-aspheric profile: a hyperprolate zone in the central 3 mm of the cornea generating intrinsic multifocality. In the hybrid version we use, the dominant eye is corrected for distance and intermediate, the non-dominant eye at -0.88 D with an add of -2.13 D to favour near vision.

The optical energy distribution is calculated with a light propagation algorithm: approximately 35-40% to near, 15% to intermediate and 45-50% to distance. We have been performing it since 2015 — over ten years of experience, thousands of patients treated. Corneal multifocality has proven stable at ten years. In the emmetropic patient — who sees well at distance without glasses but needs reading glasses — it is possible to treat one eye only (the non-dominant), fully preserving distance vision of the untreated dominant eye.

SMILE and presbyopia: monovision only

The SMILE (Small Incision Lenticule Extraction) uses a femtolaser to create and extract a lenticule of corneal tissue. It does not use an excimer laser and has no multifocal ablation profiles. Unlike LASIK and TransPRK, SMILE does not induce controlled spherical aberration — unless one manually modifies the optical zone diameter, a non-standardised approach with limited results.

In practice, with SMILE presbyopia is addressed only through monovision: different refractions are targeted for each eye, without any multifocal corneal remodelling. This is a structural limitation of the technology. SCHWIND platforms (SmartSight) offer both lenticule extraction and PresbyMAX excimer profiles on the same system — but presbyopia correction is always done via the excimer laser, not via lenticule extraction.

Summary comparison

Invasiveness and operator dependence

All surgical techniques for presbyopia are invasive at different levels. The degree of invasiveness must be understood as it determines the risk profile and dependence on the surgeon's dexterity.

What to realistically expect

Whatever the profile chosen, laser surgery for presbyopia is a smart compromise, not a cure. It does not reproduce the vision of twenty years ago — no technology today can restore the natural accommodation of the lens. The realistic goal is: reading the phone, the menu, labels and working at the computer without glasses in most daily situations. For prolonged reading of small text in dim light, or for working at the computer for hours, some patients still prefer slight support.

Ideal candidates are between 45 and 60 years old, with mild to moderate presbyopia and calibrated expectations. A small percentage may lose 1-2 lines of corrected distance acuity or perceive transient night halos — documented effects for all PresbyLASIK profiles.

ForeSight AI: simulate before deciding

Before each PresbyMAX procedure, the ForeSight system integrated in our AMARIS 1050RS simulates the expected result on real data: MS-39 topography, Peramis aberrometry, refraction. The patient sees their predicted visual profile at three distances. If the simulation shows the gain does not justify the procedure, we say so.

Prezzo

Bilateral PresbyMAX SmartSurfACE: CHF 1,500 per eye. Includes diagnostic examination, procedure, 12-month check-ups and 5-year guarantee (subject to annual check-up).

My advice

Have a diagnostic examination. It is free and lasts 30 minutes. Corneal topography with 25,000 points, aberrometry of the entire visual system, personalised predictive simulation. At the end, you will have a complete picture of what is possible in your case — and what is not. Presbyopia affects everyone. The right solution does not.