In this episode of Evidence Based Retina, Rishi Singh, MD, FASRS, discusses the latest research on presbyopia-correcting drops with Nicole Fram, MD, and Mary Beth Yackey, OD.
Dr. Fram is a managing partner at Advanced Vision Care in Los Angeles, California, and serves as an adjunct assistant professor at Moran Eye Center. Dr. Yackey is an optometrist at the Cincinnati Eye Institute, where she works in the retina department.
0.4% pilocarpine and the Bascom pupil selective analysis
The NEAR-1 and NEAR-2 trials showed that 40.1% of patients achieved three lines of improvement, while an even higher percentage (64.6%) gained two lines of improvement with 0.4% pilocarpine.1
One of the sources of apprehension in prescribing pilocarpine for presbyopia correction is the concern of retinal detachments, particularly with higher concentrations (1%) that have been previously observed. At lower concentrations, such as 0.4% pilocarpine, the risk is believed to be much lower as no retinal detachment, retinal tear, or vitreomacular traction was reported during the NEAR-1 and NEAR-2 trials.1
A recent study conducted by Orasis and Bascom Palmer faculty evaluated the ocular effects of 0.4% pilocarpine compared to 2% pilocarpine by measuring ciliary muscle thickness via OCT and dynamic OCT, pupil diameter, and lens thickness.2
While pupil diameter and lens thickness changes were observed in a dose-dependent manner, ciliary muscle thickness showed no measurable difference between the 0.4% and 2% pilocarpine groups. Although limited by sample size, these findings carry significant clinical implications, demonstrating that at the 0.4% concentration, pilocarpine does not induce ciliary muscle movement.2
Clinical evaluation and patient selection
Proper patient selection is emphasized, with the "sweet spot" for these drops identified as patients aged 40 to 55, particularly latent hyperopes and early presbyopes with good distance vision. Patients with myopia, particularly high myopia, should be excluded, and those with presbyopia should consider contact lenses or lens-based surgery for correction.
Eyecare practitioners should evaluate for existing retinal conditions, such as lattice degeneration or retinal thinning, before prescribing, as these conditions may disqualify patients from using these eye drops. Although wide-field imaging, such as Optos, can aid in assessment, it does not replace a comprehensive dilated eye exam.
Patient expectations and follow-up
Finally, clinicians should encourage patients to use the drops for a few weeks to assess efficacy before determining whether the treatment is unsuccessful. Counsel patients about potential side effects, including initial headaches, night vision difficulties, and mild stinging.
Educating patients about the warning signs of retinal issues—such as new floaters, flashes, or a curtain/veil in their vision—is an essential part of care.
