Pharmaceutical eye drops provide ‘exciting opportunity’ to personalize presbyopia care
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The practice of treating presbyopia has changed dramatically over the last several years. For our cataract patients, a proverbial arms race in the development of IOLs has afforded patients an unprecedented range of options.
Progressive and multifocal lenses make previously challenging situations, such as night driving, more manageable and rewarding. Then, the creation of the multifocal contact lens helped a wider range of patients manage presbyopia using nonsurgical, device-based solutions.
Now, we are seeing the development and commercialization of a completely novel category of presbyopia treatment: pharmaceutical drops, including FDA-approved Vuity (pilocarpine HCL ophthalmic solution 1.25%, AbbVie/Allergan) and anticipated candidate CSF-1, a preservative-free formulation of low-dose pilocarpine from Orasis Pharmaceuticals.
With an entirely new category of treatment hitting the market, physicians have an exciting opportunity to further personalize treatment plans to a patient’s life needs, desires and circumstances. But first, we must determine where and how these treatment options best fit into our clinical armamentarium, as well as consider how to best counsel patients.
Identify the right patients
The ability to treat presbyopia with drops affords us the opportunity to better accommodate a particular subset of patients: specifically, the new or emergent patient that has never worn glasses or contacts or needed cataract surgery. These patients tend to be young (45-50 years), need +1.5 D readers (or less) and typically desire a range of options for pursuing treatment. Many are motivated to reduce their dependence on readers.
Some patients might prefer glasses for specific situations, such as computer use or for around-the-clock management. Other patients, however, may prefer to avoid glasses in favor of situational or all-day contact lenses. However, another group of patients still prefer drops, as they can be used on an as-needed basis and do not require the same degree of maintenance as physical devices.
Other patients might benefit from drops but still require additional treatment solutions as part of a holistic regimen. Patients with astigmatism, for instance, may be able to use drops to facilitate computer or other task work in the morning but require glasses or contact lenses to accommodate around-the-clock function. No two patients are exactly alike, which is why it is important to fully understand the patient’s daily routine, tasks, challenges and imperatives.
Manage expectations effectively
Another important aspect to consider is the fact that patients generally want — and further, expect — perfect vision with a minimal amount of maintenance and uncertainty. How often have we consulted patients on LASIK and PRK and had to explain that surgical correction only alleviates, rather than removes, future treatment dependence? The same principle holds true here: When implemented correctly, presbyopia drops can do a great job of lessening, but not necessarily eliminating, dependence on glasses and contact lenses.
Still, by communicating the value of these new options to patients, securing buy-in and achieving long-term compliance becomes much easier. Patients that are apprehensive about drops are often pleasantly surprised to learn that by using them, they can forgo contacts or glasses in social or professional situations where they would prefer to go lens-free. In practice, we have seen that many of these patients, while not reaching sub-20/20 vision, are capable of increasing glasses- or lens-free functionality by a meaningful margin.
As with all treatment modalities, it is equally important to have an honest discussion about potential side effects and complications and include appropriate screening before, during and following treatment. Based on our clinical experience, side effects for this drug category typically include low-brow headache and blurry vision, both of which tend to appear early on and resolve fairly quickly. For patients with a high degree of myopia, it is important to discuss an increased risk of retinal detachment and have them reach out to you if they experience signs of flashes, floaters or other visual abnormalities. All patients being considered for drop treatment should undergo a thorough exam using dilation, as robust assessment of the peripheral retina is essential to ensuring safe treatment.
Define, achieve success
As clinicians, we often define success according to strict clinical paradigms, such as visual acuity improvement. Patients, however, have a much broader view of success, moving our proverbial goal post from 20/20 to “20/happy.” Patient satisfaction is crucial to ensuring long-term treatment compliance and positive life outcomes, making this goalpost important, if somewhat subjective. Having access to additional treatment modalities helps us reach this goal faster, as many patients have multiple — and often evolving — expectations regarding the role of treatment in day-to-day life.
To that end, drops for presbyopia offer a compelling advantage: flexibility. A patient that uses drops to maintain or augment their treatment can adjust usage depending on their daily needs, adding or leaning on lens-based if and when the time is appropriate. Today, patients increasingly think and act like consumers, and in the age of same-day delivery, consumers want flexibility. By presenting a low barrier to entry in terms of maintenance and commitment, drops give early and advanced presbyopes a new dimension of control over their symptom management. This flexibility often provides a real sense of empowerment, making it easier to meet expectations and deliver a positive care experience.
Jump in with both feet
As with any new treatment category, it is tempting to rely on case reports, colleague feedback and other real-world evidence before assessing its viability in your own clinical process. While that approach can be valuable, no two patient geographies are the same.
Accordingly, the best way to get comfortable with a new treatment modality is to try it on a robust group of patients. Once you have enough real-world experience under your belt, you will better understand and appreciate the advantages and challenges the modality offers your specific patients, as well as the role it can play in your clinical practice.
Implementing a new aspect into your protocol can be daunting. However, in most cases, patients appreciate access to new and flexible treatment options, making it an endeavor worth attempting.
For more information:
Cecelia Koetting, OD, FAAO, is in practice at Hines-Sight in Denver and is a member of the Intrepid Eye Society. Nate Lighthizer, OD, FAAO, is professor and associate dean at Northeastern State University Oklahoma College of Optometry, as well as a member and current president of the Intrepid Eye Society.
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