Prescription of near addition and its relation to accommodative reserve in presbyopia - The dichotomy between theory and practice

Purpose: To study the relationship between the amplitude of accommodation (AA) measured by the Royal Air Force (RAF) rule and near addition (NA) prescribed in presbyopic patients to assess how far practice is different from theoretical recommendations. Methods: Patients, aged 40 to 60 years with best corrected vision of 6/6 N5 were included in this cross sectional observational study. AA was measured using the RAF rule. Refined with near Duochrome chart, the NA was given with the chart at 40 cm. Accommodative reserve was calculated from the measured AA, NA required and the calculated additional accommodation expended by the patient for reading. The percentage of reserve was calculated with and without the correction for depth-of-field. Results: A total of 130 patients were studied. In the patients above 50 years of age, the negative correlation of AA with age was -0.298 (P = 0.065) and AA and NA was -0.365 (P = 0.002) was weak. Among the patients aged between 40 and 50 years, the negative correlation of AA with Age and NA were strong; -0.853 (P < 0.0001) and -0.823 (P < 0.0001) respectively. When prescribing glasses, 62.01% (CI 58.78 to 65.23) and 90.93% (CI 62.50 to 119.37) of the AA was found to be kept in reserve for patients below and above 50 years of age respectively. Conclusion: Accommodative reserve kept in our study patients when prescribing NA was two to three times the theoretical recommendation. High percentage of accommodation kept in reserve suggest that the measured AA is not activated normally and require higher NA and one should not rely on patient's ability to generate accommodative power especially in patients over 50 years.