Age, presbyopia stage can affect treatment journey
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When patients come to my office for comprehensive eye exams, common questions, especially for those who are in the early stages of presbyopia, include, “Why am I losing vision?” and, more importantly, “How can this be treated?”
In patients in their mid-40s in the earlier stages with mild presbyopia, I let them know it is a journey that, unfortunately, will continue to get worse with time. For those early stages, I am inclined to recommend treatment such as glasses or contacts. However, we also have pharmacologic agents at our disposal.
One of the more exciting things in this area is a new drop coming to market that will be available to our patients soon. Qlosi (0.4% pilocarpine hydrochloride ophthalmic solution, Orasis Pharmaceuticals) has the lowest effective concentration of pilocarpine of the currently available presbyopia drops.
Patients will be able to use Qlosi once or twice a day to titrate the effect. What is really exciting is that this drop has shown good efficacy and also good tolerability, with mild adverse events. Due to the lower concentration of pilocarpine, our hope is that it will be a safe drop for patients to use. I have already started having conversations with my patients that this is on the horizon, but there are other drops in the pipeline as well. Lenz Therapeutics is working on an aceclidine drop that completed phase 3 trials and may be available in the next year or so. I think there is room and opportunity for eye drops to help patients along with contact lenses and glasses.
I am more wary of offering surgical correction for patients who are in their 40s or 50s because a lot of them still have good distance vision. When I am evaluating a patient who has great distance vision and only their near vision is starting to decrease, I do not like to think about surgical options yet. It can be tough in today’s day and age of our technology to satisfy those patients completely. Even having a small refractive error after surgery for distance can be a disappointment to them. Even if they have a reduction in their presbyopia, the loss of uncorrected distance vision, even if just a small amount, can cause unhappiness and dissatisfaction. Having them work with glasses, contacts and eye drops may be a better option.
However, as they get further along the journey of presbyopia and start to lose distance vision, that is when I introduce the concept of refractive surgery and a possible refractive lens exchange, provided that they are a surgical candidate.
There are a few factors that we know are important, such as axial length, age, refractive status and history of posterior vitreous detachment. That all goes into the decision-making as their presbyopia progresses toward moderate to advanced.
When patients are losing uncorrected distance vision, that is when surgery can be more of an option. I feel much more confident now about refractive lens exchange in patients who are appropriate candidates than I did in the past. That is because our multifocal implant technology has improved. There is the PanOptix (Alcon), the Tecnis Odyssey (Johnson & Johnson Vision) and now the enVista Envy (Bausch + Lomb). All three had wonderful results in their studies, and in clinical experience, I have had great results with the modern multifocals.
A good discussion on patient expectations and potential side effects is critical. If a patient has good distance vision and is still adamant about doing some kind of refractive surgery, that is when I would probably introduce the idea of the Light Adjustable Lens (RxSight) because I want to be able to nail that distance.
I also have a discussion with them that blended vision would be needed. That is the compromise in that situation. I feel much more confident about accurately achieving their 20/20 distance, but to get them to decrease their presbyopic symptoms, we would have to offset one of their eyes for more of a near target in order to do a blended vision, a mini-monovision or a monovision.
Jennifer Loh, MD, a Healio | OSN Technology Board Member, can be reached at jenniferlohmd@gmail.com.
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