Article

New for the Presbyope: Pharmacologic Options

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WITH A CONDITION AS PERVASIVE as presbyopia—after all, it is a natural part of the eye’s aging process—it is great news that our toolbox continues to expand. The latest option, presbyopia-correcting drops, allows us to broaden our treatment capabilities and provide patients with more choices. In addition to the current FDA-approved drop already on the market (Vuity, Allergan), there are several more pharmacologic options in the pipeline. We can definitely expect this category to continue to grow.

But there are a few considerations to bear in mind before choosing a pharmacologic option for presbyopia. It might not be the right fit for every patient.

Understanding the Limitations of a Temporary Fix

First and foremost, it’s important that patients understand presbyopia-correcting drops are not a permanent solution. In fact, they aren’t really a standalone treatment option either. The drop works by constricting the pupil—and creating a pinhole effect that helps to improve near vision.

While the effects of the drop are suggested to last up to 8 hours, anecdotally speaking, most patients experience more like two-thirds to half of that time. Therefore, patients will still require a backup option, like reading glasses or contact lenses. Of course, the very fact that these drops do wear off is part of the beauty of them as a nonsurgical option. If patients do not like the effect, they are not stuck with it. It’s completely noninvasive in this way.

Knowing that the drops are a temporary solution and have a varied effect between patients, it is best to review the optimal situations in which these drops might make the most sense. Oftentimes, it’s when patients are going to be performing substantial near or intermediate-vision work, such as desk or computer work, and they don’t want to be reliant on readers the entire time. Or alternatively in a social situation, patients may like using them to be able to read a menu in a dimly lit restaurant without glasses. Ultimately, it’s a patient-driven decision as to when the drops will suit them best.

Importantly, we must be careful not to overpromise on what these drops can deliver. Since it’s something that can only last for a certain period of time, patients must understand that there are limitations.

Additionally, because presbyopia is a progressive condition, patients must also understand that their presbyopia will progress over time regardless of the temporary effect of their drop usage.

However, when viewed as a supplement to another solution, patients can really come to see the value of a pharmacologic option. While it might not eliminate readers entirely, if drops can reduce patients’ reliance on them, many will be eager to try a pharmacologic option. In fact, at our practice, many patients are initiating conversations about these drops. Consumer marketing has already helped to get the word out, and patients are reading about them ahead of their visits with me.

The price point is relatively low, and even though patients must pay out of pocket, it is not a huge investment. That has also made many patients willing to give them a try.

Educating About Side Effects

It’s also important to make patients aware of some potential side effects. In Vuity’s clinical trials, the drops were well tolerated by many patients; however, mild side effects like headaches, blurry vision, and some redness were reported.

I also tell patients that, when we are making the pupil small, as these drops do, it can also cause some dimming of vision and some loss of peripheral vision. These are important considerations as patients will want to think ahead about the optimal timing of when to use the drops during their day. It will not necessarily be an “everyday” option for all patients, but there will be some circumstances in which it’s a very helpful addition.

One less-talked-about side effect is the aesthetic impact of the drop. In reducing the pupil size, it does create a different “look” to the patient’s eyes. This should not keep patients from trying these drops, but it is something that may be worth bringing up. The starting varied pupil size is likely a consideration here as well.

In general, plan for some added chair time to educate patients about what to expect with the drops. If you already see many dry eye patients, like we do, this won’t be anything new. Be prepared to educate patients about the potential side effects while being careful not to overpromise what these drops can offer. As with any new medication, realistic expectations are key to patient success.

Optimal Candidates

Vuity was FDA-approved for patients 40 to 55 years old, which is the age range in which I am finding a pharmacologic option makes the most sense. Patients who are in their late 40s or early 50s, who have a low prescription or have good distance vision and just don’t want to wear readers, tend to be receptive and good candidates.

In these patients, their loss of near vision is still relatively mild to moderate and may not impact a huge portion of their day depending on their lifestyle and daily visual demands. Being able to use a drop when they feel like they could benefit from it is a nice option for them.

As patients progress further on their presbyopia journey, the drops might not be the best option. Fortunately, we have other presbyopia-correcting options to offer today. As patients come into cataract age, we have lens-based options to surgically and definitively treat presbyopia at its root cause. Advanced technology implants, such as multifocal and extended depth of focus intraocular lenses, have been life changing for patients and can allow for full range vision. In the meantime, these drops make a nice “nonsurgical bridge.”

Finding Its Place in Presbyopia Correction

One of the main benefits of presbyopia-correcting drops is that they give providers yet another option that they can offer patients. Patients are often frustrated as they begin to experience a loss of near vision, and they are eager to try options besides readers.

It is exciting that this is a nonsurgical option for patients who are motivated to avoid readers.It’s fair to call this pharmacological category “eyebrow raising,” as we’ve found that patients are excited about the idea. They might come to us thinking that surgery is their best option to avoid readers, and now we can talk to them about pharmaceuticals.

Plus, we know that there are additional treatments in this category on the horizon, so the options are only going to grow.

In general, however, we should not overpromise what these drops can do. It is always important to set realistic expectations. Once patients understand the nature of presbyopia and the role the drops may play for them, they do appreciate what this option has to offer. This category of therapy can be an important tool in our toolbox for presbyopes.

We have moved in an exciting direction with presbyopia—a condition that will affect everyone at some point in their lives. The more options we have, the better it will be for patients and for us as providers. At the end of the day, it’s about finding the solution that will work best for our patients. ■