Vision changes & floaters

If your reading glasses have stopped working, if you've noticed new floaters drifting across your vision, if your eyes feel dry and your prescription seems to change every six months — you're not 'just getting older'. The eye is a hormone-sensitive organ, and the perimenopausal eye changes in specific, well-described ways. Most of it's benign and treatable; a few patterns need a same-week appointment.

Dry eye gets dramatically more common in perimenopause. Estrogen and androgens regulate the lacrimal (tear) and meibomian (oil) glands. As both drop, the tear film becomes less stable, evaporates faster, and stings. Dry eye is one of the most common ophthalmology presentations in people over 45 and routinely gets dismissed as 'screen time'.

Your prescription genuinely changes in perimenopause. Hormonal shifts (and dry eye itself) alter the cornea's hydration and shape from month to month. A prescription that fluctuates by half a dioptre across a year isn't your optician being incompetent — it's the eye actually changing. Many people find they need a re-test annually rather than every two years for a few years.

New floaters are usually posterior vitreous detachment, not catastrophe. Around 50% of people experience posterior vitreous detachment (PVD) in midlife. The vitreous gel pulls away from the retina and you see cobwebs, dots or rings drifting across your vision, sometimes with brief flashes of light at the edge. PVD itself is benign and very common. But ~10% of PVDs cause a retinal tear, which can lead to retinal detachment — and that needs urgent treatment.

Presbyopia is happening anyway, perimenopause just makes it noisier. From around 40, the lens stiffens and reading distance pushes further away — this is presbyopia and it's unavoidable. Perimenopause doesn't cause it but does coincide with it, so reading glasses, then progressives, become the season's story.

Migraine aura, neck/head conditions and blood pressure can also drive 'vision changes'. Not everything that looks visual is the eye. Migraine aura, transient ischaemic episodes, raised blood pressure and even severe iron-deficiency can present as 'odd vision'. Worth naming clearly when you describe symptoms to a doctor.

Preservative-free lubricating drops, 4× a day. For dry eye, lubricating drops are the first-line treatment, and preservative-free versions (Hylo-Forte, Hycosan, Systane Hydration PF) are the better pick if you use them several times a day. Preservatives in some drops can irritate the eye surface with frequent, long-term use.

Warm compresses for the meibomian glands. A microwaveable eye mask (Bruder, Hot Eyes, Optase) for 8 minutes once a day melts the thickened oils in the eyelid glands and dramatically improves the oily layer of the tear film. The single highest-leverage home treatment for chronic dry eye.

Omega-3, 2 g/day for 3 months. High-dose omega-3 (combined EPA + DHA around 2 g/day) has moderate evidence for dry eye relief. Give it a proper 3-month trial — 6 weeks isn't enough.

Annual optometrist visit — without skipping it. From 45, an annual sight test is the right cadence (not every two years). It catches drifting prescriptions, raised intraocular pressure (glaucoma risk climbs with age) and early signs of macular change.

Photograph any new visual disturbance with a date. Floaters and aura are notoriously hard to describe accurately. A note in your phone — 'cobweb in upper-right of left eye, started Tues 4pm, no flashes' — gives the ophthalmologist usable data and makes the appointment shorter.

MHT and the eye — promising, not headline. There's emerging evidence that systemic MHT modestly improves tear production and reduces dry-eye severity. Topical estrogen drops are being trialled but aren't standard care yet. If you have severe dry eye, it's a fair question to raise with both your menopause doctor and your ophthalmologist.