Presbyopia, the age-related loss of near focusing ability, affects more than 1 billion people worldwide and has traditionally been managed with spectacles, contact lenses, or surgery—all of which have limitations. In recent years, pharmacological options have emerged as a non-invasive, reversible alternative.1
These eye drops fall into two main categories: miotics and lens softeners. Miotics improve near vision by inducing miosis, creating a “pinhole effect” that increases depth of focus. Lens softeners, designed to restore lens flexibility, initially showed promise but have largely been discontinued in development.1
Advances in presbyopia drops
A major milestone came with the FDA approvals of pilocarpine-based miotics—Vuity (1.25% pilocarpine, AbbVie) in 2021 and Qlosi (0.4% pilocarpine, Orasis Pharmaceuticals) in 2023—both of which demonstrated significant gains in near visual acuity in clinical trials. Multiple other agents and combinations, such as aceclidine/brimonidine and carbachol/brimonidine, are also in various stages of research, aiming to optimize efficacy, duration, and tolerability.1
While pharmacological treatments for presbyopia are showing strong potential, side effects and patient selection remain important considerations. Reported adverse events with miotics include headaches, redness, and, rarely, retinal complications, particularly in patients with high myopia or pre-existing retinal pathology.
However, new formulations—such as Qlosi’s lower concentration 0.4% pilocarpine coupled with its near-neutral pH—have been associated with significantly fewer side effects while still maintaining effectiveness for 6 to 8 hours, with the option for twice-daily dosing.1
We spoke with three leading optometrists about their experience with successfully introducing and integrating the newest presbyopia drops into their practice.
I adopted the first presbyopia drop early. In 2021, I built an anti-aging package and offered it as an opt-in, pairing Vuity with the first non-surgical topical drop for ptosis. The combination did well, and many patients chose it.
Results were mixed, as expected. For patients who responded, the drop worked as a useful adjunct; I still prescribed glasses in most cases, but people appreciated having options. For non-responders, the main barrier was adverse events—most often redness and headache.
There are important considerations when selecting candidates. When Vuity launched, most of the interest came from patients aged 70 to 75. They fell outside the recommended 45 to 55 range and had a low chance of success, so I did not prescribe it. I also avoided prescribing for patients who were outside the refractive range, including those with high myopia or those who could not recall their pre-LASIK prescription.
Comparing Vuity and Qlosi
I now let eligible patients know about newer options. Qlosi, the second drop on the market, has been a meaningful improvement. It is preservative-free, packaged in single-use vials, and uses a lower pilocarpine concentration (0.4% versus Vuity’s 1.25%). Its near-neutral pH and two lubricating agents improve comfort and reduce side effects. With this formulation, I haven’t seen the brow ache and redness I observed with Vuity.
For patients who start therapy, I set expectations clearly: you will still need glasses. These drops are not a permanent fix. Their effect wears off after a period of time, and you’ll need to reapply during the day. I often call it a “Cinderella drop”—when it wears off, your eyes return to baseline.
For optometrists, staying current matters. Offering safe, flexible options can improve patients’ daily lives. When it works for them, you’ll be their hero.
I was one of the early adopters in the category, and it's one that still excites me to this day. I was convinced then, and now, that there are millions of patients in the US who would benefit from taking a drop once or twice per day to reduce their reliance on reading glasses, which would be an absolute life upgrade.
My experience with Vuity was honestly mixed. I have patients who return to my clinic each week asking for refills because it helped them so much, and it actually changed their lives, while others felt it didn't do enough, long enough to justify the cost.
The headaches that patients experienced were very much a real thing as well. I believe the initial launch of Vuity, which was only approved for once-daily dosing, as well as our limited understanding of the neuroadaptation required for some patients, significantly hindered the product's launch.
Patient selection for Qlosi
The latest presbyopia drop, Qlosi, has several advantages; it's incredibly comfortable, can be dosed twice per day from launch, and Orasis has done a fantastic job with packaging and distribution—it gives off that luxury vibe that many brands strive for.
When it comes to who responds best—first off, you need a motivated patient. If the patient isn't motivated, then don't even bother prescribing it to them, at least in my experience.
For the most part, I have found that your plano distance patients who have had time to really mature into needing reading glasses for most of their near activities are absolute home runs. The patients who also seem to be a slam dunk are those post-LASIK or post-refractive surgery patients.
At this point, I find that presbyopia drops are an "and." They aren't going to solve our patients' reading issues completely 24/7; however, they are an "easy button" in terms of their near vision for many of my patients.
My experience with Vuity was only okay. Candidate selection was key in achieving good outcomes. Patients with realistic expectations and visual demands that aligned with what Vuity could offer did best. One drawback was the presence, albeit low, of the preservative benzalkonium chloride (BAK), which made me more cautious in prescribing, particularly for patients who have ocular surface concerns.
When I educate patients about presbyopia drops, I tell them it’s almost like having different types of shoes for different situations: sneakers for sports, heels or loafers for work or events. Glasses, contact lenses, and surgical options each have unique advantages, and drops are an option that can work on their own or in conjunction with other treatments.
One treatment does not replace the other; rather, they complement each other. I review what presbyopia is, how the drops work, what benefits to expect, and the realistic duration of effect. I also discuss situational use (PRN) versus daily use so patients can choose what best fits their lifestyle. The more options we provide, the more empowered patients feel to master their vision challenges.
Finding the right fit for patients
I love that Qlosi is preservative-free. With so many patients in my practice with dry eye, this makes me far more comfortable prescribing a presbyopia drop. It also contains dual lubricating agents, which further support comfort and ocular surface health.
Moreover, the lower concentration of pilocarpine compared to Vuity allows for a lower side effect profile, yet it still delivers effective results. For these reasons, I find myself prescribing Qlosi to a broader range of patients.
I would encourage colleagues to keep presbyopia drops on their radar and start the conversation with potential candidates. Early adoption allows us to gain firsthand experience, refine our patient selection process, meet evolving patient needs, and position ourselves as innovative, forward-thinking providers.
In closing
As presbyopia treatment continues to evolve, pharmacological drops are emerging as a meaningful complement to traditional options, offering patients flexibility and control over their near vision.
With improved formulations like Qlosi reducing side effects and expanding candidate suitability, these therapies are moving from niche solutions to practical tools in everyday clinical care.
By staying informed, setting clear expectations, and tailoring recommendations to the right patients, eyecare providers can help ensure this innovation reaches its full potential in enhancing quality of life for presbyopes.
