Presbyopia drops are latest reminder that category’s future remains bright

August 10, 2023

3 min read


Barnett reports commercial interest in ABB, AccuLens, Allergan, Azura, Bausch + Lomb, BCLA, Bruder, CooperVision, Dompé, EveryDay Contacts, Gas Permeable Lens Institute, Johnson & Johnson Vision Care/Vistakon, Lentechs, Novartis, Ocusoft, Orasis, Oyster Point, Percept, RVL Pharmaceuticals, Sight Sciences, Science Based Health, Scleral Lens Education Society, Sjögren’s Syndrome Foundation, STAPLE program, SynergEyes, Sun Pharma, Tarsus, Visus Therapeutics and Vyluma. Lang reports consulting for Orasis.

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Presbyopia is part of the body’s natural aging process, meaning that everybody who lives long enough will eventually become presbyopic.

Today, there are almost 2 billion people globally, and more than 120 million people in the United States, living with presbyopia. Many presbyopes express a desire to reduce or eliminate their dependence on readers. Fortunately, practitioners now have four distinct treatment options that cater to a wide range of patient lifestyles and preferences, including glasses, multifocal contact lenses, surgery and, more recently, pharmaceutical drops. Having these options at our disposal affords us a remarkable degree of versatility, as we can limit or combine modalities depending on an individual patient’s needs.

"Presbyopia is part of the body’s natural aging process, meaning that everybody that lives long enough will eventually become presbyopic.” Melissa Barnett, OD, FAAO, FSLS, FBCLA, and Jacob Lang, OD, FAAO

When the first pilocarpine-based presbyopia drop (Vuity, Allergan) became available to practitioners 2 years ago, we were eager to try out this new treatment category and learn about its real-world value firsthand.

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Here are several key learnings we’ve gathered — both regarding drops themselves, as well as presbyopia treatment more broadly — after one product launch, thousands of patients treated and countless hours with this new and highly promising treatment modality.

Patients want flexibility, control

Recent research indicates that practitioners may be lagging when it comes to meeting patients where they are. During patient assessments, many practitioners hyperfocus on trouble with reading. A patient’s daily hindrances span a wide range of activities, such as social events, athletics or general screen time. More patients are thinking beyond readers and asking what we can do for them when they’re in virtual meetings, watching a movie or out on the golf course. They want the ability to manage their symptoms when and where it’s most convenient to them, at a level of commitment they’re comfortable with.

It is imperative that we ask targeted questions to uncover needs, expectations and pain points before we start educating patients. In our practices, we are finding that after doing a deep dive and assessing a patient’s lifestyle parameters, drops and contact lenses are an attractive option, especially for patients with mild to moderate presbyopia. They provide patients on-demand flexibility and control in a fast-paced, digital-first world, reducing the burden of readers or permanence of surgery. In short, they represent a compelling, likely underutilized option and are here to stay for the foreseeable future.

New modalities require due diligence

As with any new treatment modality, it is our responsibility to do clinical due diligence and manage risk appropriately. Since the first presbyopia drop entered the market, there has been a heavy focus on risk of retinal detachment, with several events reported after launch. Most of these events stemmed from prescriptions written by general practitioners instead of eye care practitioners. It is an important reminder that novel categories come with key safety considerations, including patient selection and screening.

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For drops specifically, it is imperative to avoid prescribing them for patients with a high degree of myopia, as well as patients with existing retinal pathologies or medical history. Advanced forms of screening, such as panretinal photography in dilated eyes, are an essential precaution. Unfortunately, although these risks and investigative strategies were described in early literature, it takes time for knowledge and best practices to proliferate.

On a more positive note, there have been fewer reports of retinal detachment in recent months, indicating that practitioners are catching on and codifying these practices in their day-to-day operations. As the category continues to mature, we will remain vigilant regarding patient selection, presentation and history, just as we do during refractive surgery or multifocal contact lens consultations.

Total eye health matters

We’ve known for years that taking a complete view of eye health benefits every patient, and this is especially true where drops are concerned. Beyond checking the posterior segment for potential medical complications, it is important to pay close attention to the anterior segment, ocular surface and lid margins.

Patients may complain of blurry vision and associate it with their newly implemented drop regimen when, in reality, preexisting conditions, such as dry eye or inflammation, may be contributing factors. Evaluating the lids, lashes, cornea and conjunctiva; optimizing the tear film; and ensuring ocular surface homeostasis all contribute to better overall vision and patient satisfaction.

Small changes make a big difference

Finally, it’s also important to remember that for many patients seemingly small changes can have a large, positive impact on daily functioning and quality of life. We still have a lot to learn about eye function and optics in an increasingly device-based world, where life happens within 1 foot of a reader’s face.

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Our experience with contemporary IOLs has taught us that while we often focus on linear gains made on a chart, a patient’s overall quality of life gains may be exponentially higher if we give them modest improvements up close without sacrificing long-distance vision.

Leaning into the future

The pharmaceutical treatment of presbyopia is still a new and burgeoning category, and we can look forward to additional treatment options in the near future, including a novel, preservative-free, pilocarpine-based solution that may be approved later this year (CSF-1, Orasis Pharmaceuticals).

As the category grows, we will be able to further customize and individualize treatment to a patient’s unique needs, providing both a superior treatment experience and leaning into innovative, highly personalized care.

For more information:

Melissa Barnett, OD, FAAO, FSLS, FBCLA, is director of optometry at the University of California, Davis, and can be reached at [email protected].

Jacob Lang, OD, FAAO, practices at Associated Eye Care in Minnesota and can be reached at [email protected].


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