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Bye Bye Presbyopia

This post is also available in: French

Presbyopia can be reversed or delayed by teaching patients cross their eyes while using the Presbyopia Reduction Chart. I first used this in 1976 with a 52 year-old hyperope with 20/200 near and 20/40 distant acuity. He had normal, bifocal-wearing, middle-aged vision and had been wearing reading glasses and bifocals since age 40. After teaching him the Bates palming, sunning and fixation drills, I taught him converging (crossing his eyes) and diverging (uncrossing his eyes) exercises using a chart with a pair of targets separated horizontally by two inches. Two weeks later his acuity had cleared to 20/40 at near and 20/20 at 20 feet. How did he do it? He loved the converging exercise and practiced whenever he had a chance. At work he would spin around in his executive swivel chair converging and diverging the targets. Did it last? Three years later, at age 56, his vision was even better.

I can read tiny print without strain even at age 59. When I started to need reading glasses at age 40 or 45 I practiced with this chart for several months and improved my condition. My near vision is still clear although every few months it starts to blur and I worry that presbyopia has finally caught me. But it hasnt because I get out my trusty Presbyopia Reduction Chart and exercise for fifteen minutes several times a day while relaxing to let the small print clear. After a few days my focus returns and I dont have to exercise for another few months. I don’t know if there is an upper age limit. Recently I was encouraged when a 75 year-old optometrist who has been wearing +2.50 D trifocals for 20 years practiced the exercise. After four months he could read the tiny print on the presbyopia chart with no Rx without converging. Other optometrists report similar results.

Many of my patients gain sharper vision and also feel better in their eyes. They enjoy doing the exercise because it feels good even though many had to struggle or were uncomfortable at first. They also do Bates’ palming and sunning exercises to relax their eyes and increase ocular circulation. But not everyone improves even with dedicated practice and not all patients can learn to do the exercise. Strabismics and people with binocular problems can’t. They require more basic vision therapy procedures. Poor convergers have to first build convergence with near-far jumps and near-point pursuits. In some cases these exercises cause great discomfort. These patients must be warned to limit their initial convergence workout to just 30-60 seconds at a time. They can practice several times a day but just for very short periods. As they get stronger and more comfortable, gradually increase practice to ten or fifteen minutes at a time. How do patients learn to use the Presbyopia Reduction Chart? If a patient can easily cross their eyes, hold the chart 16 inches away, have them “go cross-eyed” and direct their attention to the black circles near the top of the page. Move the chart closer and farther until they see three dots. Always make sure the dots are level or parallel to the eyes to avoid inducing vertical disparity.

Patients who cant easily cross their eyes can learn to converge using a pen (or their finger) as a fixation target. Place the tip on the Presbyopia Reduction Chart between, and just under, the top pair of dots. Patients are to look at the pen while slowly pulling it nose-ward. Ask how many dots they see behind the pen. If they report four, the pen needs to be moved closer in or farther away. When the pen is about halfway to the page, three dots will magically appear. This is a big thrill for most patients. Practice until they can fixate the pen and see three dots. (Hint: If only two dots are reported (or they lose three) its usually because patients forget to keep their eyes on the pen. They look at the dots instead. Watch their eyes. If they stop aiming at the pen, touch it to remind them where to look. Make them aware of when the pen doubles.)

Help patients gain strength by having them move the pen and chart together to the right, left, up, down, closer, farther, or in a circle and to keep seeing three dots while standing up, walking and sitting down. Remind them to blink and breathe to keep strain to a minimum. The target must not tip down on one side.

The next step is to see three after removing the pen. Begin by having patients make brief blinks while converging the pen. Do they retain convergence and three dots? Try blinking more slowly. This helps patients feel convergence. Now ask them to pay attention to the middle dot without losing it by moving their mind to the dots while aiming their eyes at the pen. When they can actually attend the middle dot without losing it, have them slowly remove the pen. They’ll usually see triple dots without a pen for just a second or two at first. Success comes quickly with practice. Once they can hold three without the pen, practice moving the target as described in the paragraph above.

Now that they can fuse without the pen, most patients spontaneously look at the words in the paragraph around the dots. Have them look for details in the big letters and then move to smaller print. If they have difficulty moving from dots to print, let them use the pen for support. Soon most will be able to move their converged eyes around page without the pen. Teach them to relax to read the small print.

Compare acuity by testing vision first by looking normally. Measure how far down the print is legible before it is too small to read. Then test again while converging the targets. Near vision should be significantly clearer while converging. This improvement motivates patients to practice. They should do the exercise for at least ten minutes several times a day for a month or longer to regain accommodation. Bright light increases clarity. To improve near acuity, start in high brightness. As the letters clear, reduce the light until you can clear them in dim or even in candle light. Go back to the bright light and try again with smaller print. Also try working at twelve, ten or even six inches away. Change the brightness, nearness and text size to find the limits of your near vision. Stay on the edge of what you can just see clearly and as it becomes easier, slowly move into more demanding conditions. Eventually near focus clears at the reading distance without glasses and without needing to converge.

The paragraphs are positioned on the page to appear in 3-D. Converging two adjacent paragraphs makes just the middle one sink behind the others. Diverging produces the opposite: the center paragraph floats between you and the page.

Although the Presbyopia Reduction Chart mentions only convergence, divergence is also important. To teach patients to diverge the targets have them place the page on their nose with the top pair of dots right in front of their eyes. Encourage them to pretend to look through the dots into the room beyond the page. They should see one big dot right in front of them. If so, slowly move the page away until they see three. Warn them to not look directly at the page but to stay loose and be aware of the whole room in their periphery. Another way is to fold the top of the chart down so the dots are just at the top. Look at an object several yards away. Bring the dots up from below until they are just under the lines of sight at about 14 inches. See three dots below? If so, slowly move the chart up without changing eye position. Try to keep three dots while looking at the center one.

If these methods fail, copy the Presbyopia Reduction Chart on transparency or punch a hole the middle of the dots to look through. This allows them to look through the chart (diverge) and see three dots. The trick is to look at the center dot without losing it. Patients with convergence excess (also called esophoria) cant diverge easily. They try too hard causing them to converge more instead of letting go. Myopes usually do better at divergence without glasses. Plus lenses and base-out prisms can help others to learn to diverge. More extensive vision training may be necessary. Eventually you want patients to be able to diverge the targets easily and to see the print clearly. Diverging should cause the middle paragraph to appear to float closer to the patient, above the rest of the page. Practice moving the target and walking as described above.

Patients should practice both diverging and converging each time, although usually one way is practiced more than the other. They should also practice with and without their glasses. Eventually you want patients to be able to jump between diverging and converging the targets, quickly and with clear vision. This stretches accommodation and convergence ranges even more.

By Ray Gottlieb, O.D., Ph.D.
raygottlieb@excite.com