Presbyopia is, as Dr. Mark Schaeffer puts it, undefeated. It catches up with everyone, and the prescription pad has finally caught up with it. There are now four FDA-approved presbyopia drops on the market: QLOSI, VIZZ, Vuity, and YUVEZZI.1,2,3 With more options comes a more pressing question for clinicians: which one to prescribe, and for whom.
In this iteration of Presbyopia Playbook, Dr. Schaeffer sits down with Dr. Mark Dunbar of the Bascom Palmer Eye Institute to walk through new imaging data on ciliary muscle thickness with QLOSI (pilocarpine 0.4%), and what pupil selectivity actually means for the safety profile of these drops in real-world prescribing.
Why pupil selectivity matters in presbyopia drops
Presbyopia drops work by creating a pinhole miotic effect, typically with pilocarpine. The pupil constricts, depth of focus increases, and patients can read again without their cheaters.
The trade-off is what pilocarpine does behind the iris. Higher concentrations cause ciliary muscle contraction, which can pull the vitreous forward. In a pre-PVD population, roughly 45 to 65 years old, that traction has long been theorized to raise the risk of retinal tears and detachments.4
That theoretical concern became reality after Vuity (pilocarpine 1.25%) reached the market. Within months of commercial release, case reports of retinal detachment and vitreomacular traction following Vuity use began appearing in the literature.4
The FDA Adverse Event Reporting System (FAERS) Public Dashboard subsequently accumulated dozens of reports of retinal detachment, retinal tears, and vitreoretinal traction associated with Vuity, prompting an expanded warning label.5 Clinical trials had not flagged these signals, but post-market data did. That history made selectivity central to QLOSI's development.
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Presbyopia Handout
Download this ready-made, patient-friendly resource that explains presbyopia in plan language to reinforce chairside counseling, anser common questions, and support treatment adherence without eating into appointment time.
Inside the Bascom Palmer ciliary muscle imaging study
To find out whether QLOSI achieves that selectivity, investigators at Bascom Palmer, part of the University of Miami, designed a study using a custom OCT capable of measuring ciliary muscle thickness in vivo.6
Ten patients were imaged after instillation of three different solutions:
- Pilocarpine 2% (high-concentration reference)
- QLOSI (pilocarpine 0.4%)
- Balanced salt solution (control)
Ciliary muscle thickness was measured at distance and at near for each condition.
The result: QLOSI 0.4% behaved almost identically to the balanced salt solution. There was no meaningful ciliary muscle contraction.6 Pilocarpine 2%, by contrast, produced the dramatic shift you would expect from a high-concentration miotic.
“It really signifies that concentration is important. The 0.4% pilocarpine didn't have much of an effect on the ciliary muscle, thus minimizing the risk of retinal detachment, while still giving us the desired miotic effect.”
What this means for retinal safety
The clinical logic is straightforward: if the ciliary muscle isn't contracting, the vitreous isn't being pulled forward, and the mechanical risk of traction-related retinal events drops accordingly.
Real-world data so far supports that mechanism. Dr. Dunbar notes that the FAERS database has remained essentially clean for QLOSI since its commercial launch in early 2025, with no reports of retinal detachment, retinal tears, or vitreomacular traction surfacing in the post-market window.7 The imaging data explains the physiology, and the FAERS record confirms it is holding up in-clinic.
Choosing between presbyopia drops in practice
Pupil selectivity isn't the only factor in the prescribing decision. Dr. Dunbar weighs QLOSI against VIZZ, the other newer entrant, on two practical axes: duration and tolerability.
VIZZ (aceclidine 1.44%, LENZ Therapeutics) offers a longer duration of action, with clinical trials demonstrating efficacy for up to 10 hours after instillation.2 QLOSI runs shorter, but in Dr. Dunbar's experience tends to be better tolerated, with less redness and irritation thanks to its near-neutral pH formulation.
“Do you really want a drop that lasts 8 hours plus if you're not really totally comfortable with it?”
For many patients, the trade between duration and comfort lands in QLOSI's favor. Dr. Schaeffer adds a counseling note that applies across the category: don't have patients try a presbyopia drop for the first time at night before driving to dinner.
Dim vision is a known class effect of miotic agents, and the Vuity prescribing information specifically advises caution with night driving and other activities in poor illumination.8 A daytime trial run avoids a bad first impression.
Take home
Presbyopia drops are elective, which means the risk-benefit conversation matters more, not less. Patients are not facing a sight-threatening disease. They are choosing between this and reading glasses.
That is where the Bascom Palmer data is useful. Knowing that QLOSI 0.4% mimics balanced salt solution at the ciliary muscle gives prescribers a mechanistic reason for confidence beyond clinical trial endpoints. Combined with a clean FAERS record, it shifts the conversation from "is this safe?" to "which option fits this patient?"
