On this episode of Presbyopia Playbook, Marie Huegel, OD, FAAO, and Mark Schaeffer, OD, FAAO discuss how presbyopia can be treated with new lower-dose pilocarpine eye drops that help patients avoid adverse effects of the medication.
Dr. Huegel is a member of the American Optometric Association (AOA), a fellow of the American Academy of Optometry (AAO), the North Carolina Optometric Society (NCOS), Women in Eyecare - Charlotte Chapter, and the Vice-President of the Piedmont Optometric Society and is a practicing optometrist in North Carolina.
Presbyopia fast facts
- Presbyopia is the gradual, age-related loss of eye lens flexibility that makes it difficult to focus on close objects.
- A 1.25% pilocarpine dose, marketed as VUITY, was FDA approved in 2021 for treatment of presbyopia. A new 0.4% pilocarpine option, QLOSI, was FDA approved in 2023.1,2
- Common side effects of pilocarpine eye drops include vision changes, eye irritation and brow ache.3
- Pilocarpine constricts the pupil to create a "pinhole effect" that increases the depth of focus and makes it easier for the eye to focus on close-up objects.
Lower-dose pilocarpine drops improve tolerability
For many presbyopia patients, readers, progressives, and contact lenses just aren’t cutting it. In 2021, the FDA approved VUITY, a 1.25% pilocarpine eye drop, for the treatment of presbyopia.1 “I think we were all super excited. Patients were excited because we finally had another tool in our toolbox to help improve their near vision without reaching for readers,” said Dr. Huegel, referring to VUITY when it first hit the market.
“I think a lot of us were excited and kind of jumped on board, but the more we learned about the adverse reactions and how patients responded to the overall eye drops, I think that's where [we re-evaluated] the overall efficiency and how we use the eye drop.”
Practitioners found that patients’ tolerability of adverse side effects was lower when pilocarpine was used to treat presbyopia rather than more severe conditions, such as glaucoma. “When you're talking about an elective refractive care drop where we're substituting the need for glasses and contact lenses, you need that to be a lot more comfortable because we aren't saving vision,” emphasized Dr. Shaeffer.
A formulation developed with adverse effects in mind
At the 1.25% pilocarpine formulation, many patients complained of side effects, including eyebrow pain, headaches and dim vision. To address these concerns, Orasis developed an FDA-approved lower-dose pilocarpine eye drop, QLOSI, which contains only 0.4% pilocarpine, potentially reducing the incidence of patient side effects.2
“Pilocarpine is actually where you get a lot of the burning and stinging,” said Dr. Huegel. “I think when you actually look at the clinical data behind how Orasis went about this, I think they were very strategic. They really wanted to shoot for the lowest concentration where we have minimal side effects while also providing the most effective pupil size.”
She added, “Orasis corrects many of the problems with the VUITY eye drop in the QLOSI formulation: it’s preservative-free, has lubricating components and doesn’t sting. I've tried it. It's comfortable.”
Download the patient handout here!
What You Need to Know About Presbyopia
Use this handout to guide patient education on presbyopia and available treatments in the office and as a resource for patients to take home and review later.
Who is the ideal patient for low-dose pilocarpine drops?
Dr. Huegel recommends early-to-moderate presbyopic patients for low-dose pilocarpine treatment. Ideally, she suggests emmetropic patients in a range of a +2.00 hyperope to a –4.50 myope for best results.
Further, patients can choose how often they repeat the dose. “Whether it's doing one drop or if you want to repeat the dose 2 to 3 hours later, I let patients decide how much near vision they want to improve,” said Dr. Huegel.
Education helps patients know what to expect
Dr. Huegel emphasized the usefulness of education to set reasonable patient expectations. She explained that educating patients about pilocarpine eye drops is similar to preparing patients for progressive or multifocal lenses.
Though it takes additional time, providing a thorough explanation of how the drops behave as well as guidance on potential adverse events will lead to greater patient confidence and overall success.
Conclusion
“Every patient wants the luxury of choice,” commented Dr. Schaeffer. “The more we gatekeep these treatment options, the more patients get frustrated with their options.”
Dr. Schaeffer underscores that patients would prefer to learn about new treatment options at their eye exams instead of through social media, and he encourages practitioners to present patients with all of the potential options and let patients decide the best course of action.
When it comes to low-dose pilocarpine drops, Dr. Huegel highlights the benefits of the therapy for patients that are dissatisfied with contacts or lenses for presbyopia treatment. “Look at the clinical data. The formula is preservative free with single-digit adverse reactions. We know it's safe and also therapeutic and can provide improvement to 20/40 vision without compromising distance vision,” she said.
This article was written by Katharine Sharpe, MS, based on the recorded conversation between Drs. Schaeffer and Huegel.
