Array of options available for presbyopia treatment
Presbyopia is the second most common refractive error in the United States, with about 128 million of 335 million Americans, or 38% of the population, being presbyopic. Myopia today is slightly higher at 42% of the population.
Globally, it is estimated that 2 billion of the world’s 8 billion inhabitants are presbyopic.
All of us who have reached the presbyopic age know that uncorrected presbyopia is a significant handicap in modern-day life, where near tasks have become increasingly important in the digital age. Presbyopia is an aging degeneration caused by loss of elasticity of the natural lens. Of interest, presbyopia was not a significant issue for humankind until the 20th century, as life expectancy was less than 40 years until the 1900s. Today, eye care professionals manage the handicap of presbyopia with eyeglasses, contact lenses, refractive surgery or eye drops. A few thoughts on these four modalities.
The first reading glasses appear in writings around 1300. In those days, it was the rare individual who lived long enough to need them. Benjamin Franklin is credited with inventing the first bifocal eyeglasses in 1785 for his own use as he reportedly detested readers. In advanced countries, reading glasses and bifocal or trifocal spectacles with various optical designs are available to most. In less affluent countries, as many as 2 billion people suffer the handicap of a refractive error without access to spectacle correction. It might surprise many that uncorrected refractive error is a major cause of visual dysfunction globally. In the U.S., just more than 60% of presbyopes prefer reading glasses, and the rest use multifocal spectacles. With modern eyeglasses, quality of vision is excellent at all distances as single images are presented to the retina for every distance rather than overlapping or compromised images. More about that later.
We have learned that while quality of vision is excellent with spectacles, some patients find dependence on them to represent a handicap and generate decreased quality of life and self-esteem. The first widely used alternative was the contact lens. Bausch + Lomb and Wesley Jessen pioneered presbyopia-correcting contact lenses in 1981. Multifocal contact lenses, like IOLs, utilize refractive or diffractive optics and higher-order aberrations such as spherical aberration to create two or more overlapping images or an increased depth of focus. In both approaches, there is a reduction in quality of vision at every distance and secondary unwanted positive dysphotopsias, especially halos. For this reason, about 25% of presbyopic contact lens users prefer monovision, and many happy pre-presbyopia contact lens wearers discontinue contact lens wear when they become presbyopic. New contact lens designs are being pioneered by companies including Lentechs, which is developing a progressive contact lens that allows quality vision at all distances like that available with spectacles.
Refractive corneal surgery and refractive lens surgery are the third option available to overcome presbyopia. In refractive corneal surgery, the use of intracorneal lenses with a center-surround bifocal approach or small-diameter aperture optic has been utilized. To date, neither has achieved widespread adoption. Excimer and femtosecond lasers have also been used to induce spherical aberration into the cornea, increasing depth of focus, and while this approach has advocates, no treatment algorithm has achieved FDA approval in the U.S. In contrast, we have many FDA-approved extended depth of focus (EDOF) and multifocal IOLs with increasing adoption after cataract surgery or during refractive lens exchange. Multifocal phakic IOLs are also becoming available in some parts of the world. In development are many next-generation accommodating IOLs that promise enhanced quality of vision with less dysphotopsia when compared with EDOF or multifocal IOLs. I personally see our future surgical treatments for presbyopia dominated by lens-based refractive surgery solutions rather than cornea-based refractive surgery approaches.
Newer yet is the development of pharmacologic agents for refractive correction (PARC). The first eye drop FDA approved to enhance near vision was Vuity (AbbVie), which utilizes 1.25% pilocarpine in a proprietary vehicle to induce pupillary miosis, increasing depth of focus and enhancing uncorrected near vision. Qlosi (Orasis Pharmaceuticals) with a lower 0.4% pilocarpine has also achieved FDA approval and will launch in the United States this year. I anticipate we will see many PARC alternatives enter the market in the next decade, including low-dose topical atropine eye drops for progressive childhood myopia (Sydnexis), eye drops to cross- link the cornea in keratoconus (Glaukos) and several more miotics that promise to not only enhance near vision but also improve distance vision and/or reduce unwanted nighttime dysphotopsias for many people. I see PARC joining spectacles, contact lenses, and refractive corneal and refractive lens-based surgery as commonly used therapies for the correction of refractive errors including presbyopia in the next decade.
As life expectancy increases worldwide, the need to manage presbyopia will grow in every eye care professional’s practice. Fortunately, innovation in this vertical is well supported with human and financial capital, so we can expect ever better treatments for presbyopia — a win-win-win for our patients, our practices and the industry that supports us.
- Reference:
- Demand will continue to grow for pharmacologic, lens-based presbyopia treatments. https://www.healio.com/news/ophthalmology/20230103/demand-will-continue-to-grow-for-pharmacologic-lensbased-presbyopia-treatments. Published Jan. 4, 2023. Accessed Jan. 27, 2025.
- For more information:
- Richard L. Lindstrom, MD, can be reached at rllindstrom@mneye.com.
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