Presbyopia-correcting drop options a win for eye care providers, patients
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Presbyopia is a very common age-related process that negatively impacts visual performance and quality of life. Nearly 120 million people in the United States and 2 billion around the world are impacted by presbyopia, and with the aging population the number increases every year.
This is an area of personal interest, and I disclose that I consult widely in the field. A few thoughts after helping develop several surgical approaches for the treatment of presbyopia: first, the presbyopic patient is very risk averse. Even though presbyopia has a meaningful negative impact on an individual’s visual performance and psychological well-being, presbyopic patients strongly desire a treatment that is very safe and preferably reversible. For this reason, most presbyopic patients have rejected the many refractive surgical treatments developed over the years, even those that received regulatory approval. Procedures that have failed to succeed in this demanding market include incisional keratotomy, conductive keratoplasty, laser and manual automated lamellar keratoplasty/keratophakia, so called PresbyLASIK and intracorneal lenses to name a few. While effective and quite safe in the emmetrope and hyperope, even refractive lens exchange with one or another advanced technology IOL implant only attracts a small number of patients each year. Yet, many presbyopic patients remain disappointed with the spectacle and contact lens alternatives currently available.
The next approach about to launch into the U.S. marketplace is the use of miotic eye drops to reduce pupil size and increase depth of focus. A reduction of pupil size to between about 1.6 mm to 2.2 mm can improve near vision in most patients 2 to 3 lines in a bright light environment. To put this in perspective for the clinician, a 2-line improvement in near vision is about what one achieves with a +1.00 D reader and a +1.50 D reader improves near vision about 3 lines. My clinical experience suggests truly comfortable near vision with a normal reading speed requires vision as we measure it clinically of Jaeger 2 or 20/25 in Snellen notation. This suggests to me that presbyopia correcting eye drops will be mainly for the mild to moderate presbyope, probably between age 40 to 55 or, at most, 60. A short acting drop will be preferable for most patients, as miosis can impact distance vision, especially in dim light. A near vision improving eye drop that is desirable during an evening dinner engagement may be less desirable during the dark drive home. I think a duration of efficacy of 2 to 4 hours will be good for most patients in most settings, and if a longer period of near vision enhancement is desired, a second or even third drop can be taken as needed.
The side effect profile of miotic drops is well known after decades of use in glaucoma therapy. Fortunately, we are using a low concentration of miotic, so severe complications such iris cysts and retinal detachment are unlikely. Some patients will notice a mild brow ache or frank headache, and this is less frequent with lower concentration miotics. Mild conjunctival hyperemia is possible and can be reduced with vasoconstricting drops if a concern. This is a drop that will lend itself readily to a therapeutic trial in the office since the onset of action is only 15 minutes, or a sample can be sent home with the patient to trial.
The anticipated launch of eye drops to reduce the near vision deficit inherent in presbyopia will bring many new patients into we eye care providers’ offices. Both ophthalmologists and optometrists will be treating these patients. I believe many emmetropic patients will get their first ever eye examination because of this presbyopia eye drop product launch. That will be a virtue, as much undiagnosed pathology including ocular surface disease, cataract, glaucoma, macular and retinal pathology will be diagnosed allowing timely treatment.
Not every eye doctor will be motivated to see these patients, but every office will need to plan how they will manage these patients when they call. Miotic drops for the treatment of presbyopia will be the first chapter in the pharmacologic treatment of refractive errors. These drops will also enhance distance vision for many patients by reducing the impact of small refractive errors, higher order aberrations and corneal irregularities. Next in line will be low dose atropine for the treatment of progressive myopia, and at a future date, topical eye drop therapy for progressive keratoconus.
We are entering an important new era in the treatment of refractive errors with eye drops, starting with presbyopia. I see this as a win for patients, eye care providers and industry.
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