An unusual case of presbyopia

This well-dressed, well-groomed 42 year old woman came to my office complaining about blurry near vision for the past week. Her vision was 20/20 in each eye without any correction for distance. At near she did have difficulty and required a +1.75 add to read 20/20. Her eyes were healthy otherwise. I came to the only diagnosis that is presbyopia and educated her on this subject. 

She never wore glasses before and had always had good vision. She was quite depressed about the prospect of aging and could not believe that this happened to her.

To me it’s such a normal diagnosis, I did not think twice about it. Too bad this happened to her, but won’t this happen to everyone eventually?

I gave her a prescription of progressive lenses and asked to see her again in 1 year.

4 days later, she came to my office again. The appointment note said to re-evaluate vision. I was surprised and annoyed – why wouldn’t people accept the fact that they are getting older?

She sat down and started with “ Doctor, I have some good news that will change the prescription you gave me last time.” 

“What kind of good news will that be?” I thought to myself.

“My husband found this patch behind my ear that I forgot to take off after our vacation…”

“Oh my god” I said to myself silently. Of course it’s the scopolamine patch that everyone forgets about, which then gets absorbed by the skin and works to knock out the accommodation of the eyes, leading to the blurry near vision.

So the mystery is solved. This is not a usual case of presbyopia after all. My patient is a victim of drug-induced cycloplegia. 

She does have some eye strain after using computers for a long time. So I gave her a prescription of +1.00 add for near work as needed. I did tell her about the OTC readers, but she preferred prescription glasses.

Reflecting back on her case, her symptoms were newly onset, almost sudden onset, this is kind of a red flag, because presbyopia comes up gradually. Further, she’s not a latent hyperope, so +1.75 add was too high for her age. It’s her age that fooled me. If she were 20 years old, I would have investigated further.

Lesson learned: if accommodation is not what it should be, always ask about scopolamine patch. 

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