Presbyopia After 40: Why Close Vision Gets Worse and What You Can Do

To see clearly up close, the eye has to increase the optical power of the lens. A young lens is elastic: when the ciliary muscle contracts, the lens becomes more curved and bends light more strongly. With age the lens hardens and its ability to change shape declines, so this mechanism gradually fails. A review in the BCLA CLEAR series describes this as part of a progressive process of cross-linking (stiffening) of eye tissues, which involves among others the lens and the sclera, that is, a whole-body phenomenon and not 'tiredness' of a muscle that can be trained.

The exact role of the individual structures (lens, ciliary muscle, sclera) is still debated. The same paper recalls, for example, Schachar's theory, according to which the key is a reduction in the space between the ciliary processes and the lens; the authors call it controversial and challenged. For the patient the practical conclusion is the same: the process is physical and progressive, does not depend on 'effort' or the 'fitness' of the muscles, and so cannot be reversed by exercises.

It is important to distinguish it from other refractive errors. Short-sightedness, long-sightedness and astigmatism concern the shape of the eyeball or the cornea and occur regardless of age. Presbyopia is superimposed on them: a person with uncorrected long-sightedness will notice it earlier, and a short-sighted person may read well for years after taking off distance glasses (which is why it is sometimes mistaken for 'improving eyesight'). You should not, however, assume by yourself that age is the only cause if your vision changes suddenly.

In the update on this topic in the BCLA CLEAR series (Markoulli et al., 2024) it was pointed out that functional presbyopia affected about 24.9% of the population in 2015, and the forecast for 2030 is about 24.1% (because of rising myopia) but 2.1 billion people because of demographics. Risk factors for earlier onset included environmental factors, nutrition, intensive near work, refractive errors, accommodative dysfunction, medications, certain health conditions and sleep. These are associations from observational studies that may help explain why the onset differs between people, but they do not provide ready-made ways to delay it.

A check-up with an ophthalmologist or optometrist is needed not only to choose glasses but also to exclude other causes of worse near vision and eye strain: uncorrected long-sightedness or astigmatism, dry eye, early cataract, fluctuations of blood sugar in diabetes (a changing glucose level can temporarily change refraction), the effects of some medicines. A sudden change of vision in one eye, eye pain, flashes, a shadow in the visual field or double vision are not presbyopia and need urgent consultation. We write about floaters and flashes separately in our article on eye floaters.

A good moment for the first examination is when symptoms appear, and for people without complaints a periodic check after forty, which also allows intraocular pressure and the fundus to be checked. A first pair of 'reading' glasses from a pharmacy or shop can be a temporary solution, but ready-made lenses have the same power in both eyes and no astigmatism correction; where the eyes differ, individually fitted correction is better.

Glasses have been the basis of presbyopia correction for decades. The review in the BCLA CLEAR series on contact lenses and spectacles lists the spectacle options: single-vision lenses (e.g. for reading), bifocals and progressives (gradually changing power). Contact lenses come as soft multifocal (simultaneous), rigid translating or simultaneous designs, and in a monovision arrangement (one eye for distance, the other for near). Each solution requires adaptation and is not ideal in every situation.

Evidence for the superiority of one procedure over another is surprisingly modest. The 2025 Cochrane review (Alvarado-Villacorta et al.) assessing surgical interventions for presbyopia found only four randomised trials, 300 participants in total (600 eyes), from Croatia, Egypt and Turkey, without follow-up beyond 12 months; because of insufficient data for comparisons no meta-analysis was performed. The practical conclusion: a procedure is a sensible option for selected people after a conversation about risks and trade-offs, but there is no hard evidence on which one is best.

A pharmacological option has become available only recently. In 2021 the US FDA approved 1.25% pilocarpine eye drops (Vuity) for the treatment of presbyopia, as mentioned in reviews. Pilocarpine acts on muscarinic receptors, constricts the pupil and increases the depth of focus, while also improving accommodation, so it 'brings the image closer', like a small aperture in a camera. It does not reverse ageing of the lens; it works for several hours after instillation.

What follows, honestly? The drops improve near vision in roughly one person in three (by at least three lines on the chart), and in most of the others the improvement is smaller or absent; the effect is short-lived, and the results concern people aged 40-55 and an observation period of up to about 30 days. Constriction of the pupil (on average by 1.38 mm in the meta-analysis) can worsen vision in dim light, and a full eye examination should precede a decision on such drops. We did not check whether and in what form such drops are registered or available in Poland, so we do not state this as fact; availability should be confirmed with an ophthalmologist and in official sources.

The market offers 'eye' supplements, eye-training apps and exercises that are supposed to 'restore the elasticity of the lens'. Our search of publication databases did not find convincing studies in which such interventions reversed presbyopia. In the search we found only a protocol of a planned randomised trial of a traditional yogic eye-cleansing method, that is, a description of what is yet to be tested, not a result. The discussion of pharmacological and nutritional approaches in the BCLA CLEAR series presents them as research questions, not as established treatment.

What can make sense is ergonomics of near work: good lighting, an appropriate distance from the screen and breaks, which reduce eye strain but do not change presbyopia itself (we write more about this in our article on digital eye fatigue).

Presbyopia is one of the few complaints of middle age for which we have a simple, cheap and effective answer. Reliable evidence (including a randomised productivity trial) shows that near glasses genuinely improve functioning. Newer options such as drops give a short-lived effect and have their own limitations, and promises of 'reversing' presbyopia with exercises or supplements have no basis in research. We therefore recommend an eye examination, choosing correction to suit your own needs, and treating new methods with cautious interest.