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Drops may offer another possible way to eliminate presbyopia
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Presbyopia is a very common condition and can present a significant handicap for many in life’s daily activities. I am a slightly hyperopic presbyope and find the reduced function more than a nuisance.
The incidence of presbyopia varies by country and is, of course, higher in the advanced countries with a large older baby boomer generation than in the emerging countries where the population is younger. In America, at least 100 million suffer from some level of presbyopia, and globally, the number is well more than 1 billion. Most are treated with spectacles where available, but in many parts of the world, even spectacle correction is not available. A small number are corrected with monovision or multifocal contact lenses.
Surgical remedies are expanding. Excimer laser corneal refractive surgery or IOL-based refractive cataract surgery using a monovision outcome has been available for many decades and remains the most common surgery my refractive surgeon colleagues around the world and I do for presbyopia. Various so-called excimer laser-induced “presbyLASIK” patterns have evolved using the classic aspheric, center near/periphery distance and center distance/periphery near patterns pioneered in contact lenses. These treatments have worked well for select patients, but the same reduced contrast sensitivity and night vision issues experienced with multifocal contact lenses and IOLs have limited them from achieving broad acceptance.
Intracorneal inlays for presbyopia are now becoming available and are implanted in just one eye, using a modified monovision approach. I have implanted both the AcuFocus Kamra inlay and an earlier generation of the Presbia hydrogel inlay. Most patients have done well, but a small number do not achieve good near, lose too much distance, suffer from reduced quality of vision, have night vision symptoms, or have issues with decentration or interface healing. In these patients the inlay is usually removed. Fortunately, like a multifocal IOL, a corneal inlay can be explanted if needed.
Ultimately, we would all love to have a medical treatment for presbyopia. Two approaches are showing promise. One is a drop that generates a miotic pupil, resulting in increased depth of focus like the Kamra inlay and IC-8 IOL. The drops last 6 to 8 hours and can be used intermittently as patients desire. The other, a drop developed by Encore Vision, utilizes a custom formulation of alpha-lipoic acid to increase the elasticity of the normal human lens, potentially restoring natural accommodation. Phase 2 clinical trials of this drop are promising, and to me this is the most exciting development in the field of presbyopia treatment.
Perhaps there will be a time when myopia, astigmatism and hyperopia can be treated with genetic engineering and environmental modification, with presbyopia eliminated by drops. That would be an amazing and, to me, imaginable future.
Disclosure: Lindstrom reports he is a consultant for and investor in AcuFocus and Encore.