In this episode of Inside Intrepid, Mary Beth Yackey, OD and Janelle Davison, OD sit down to review pearls for successfully implementing and prescribing presbyopia drops.
Dr. Yackey is an optometrist in a retina specialty practice at Cincinnati Eye Institute in Cincinnati, Ohio. Dr. Davison is the owner and CEO of Brilliant Eyes Vision Center in Smyrna, Georgia, and the owner and Clinical Director of Visionary Dry Eye Institute.
Presbyopia eye drops fast facts
- There are currently four FDA-approved presbyopia eye drops:
- VUITY (Pilocarpine hydrochloride ophthalmic solution 1.25%, Allergan, an AbbVie company)1
- FDA approval: 2021 (brandname no longer available)
- Mechanism: Nonselective muscarinic agonist
- QLOSI (Pilocarpine hydrochloride ophthalmic solution 0.4%, Orasis Pharmaceuticals)2
- FDA approved: 2023
- Mechanism: Lower-concentration pupil-selective muscarinic agonist
- VIZZ (aceclidine ophthalmic solution 1.44%, LENZ Therapeutics)3
- FDA approved: 2025
- Mechanism: Pupil-selective muscarinic agonist
- YUVEZZI (Carbachol and brimonidine tartrate ophthalmic solution 2.75%/0.1%, Tenpoint Therapeutics)4
- FDA approved: 2026
- Mechanism: Muscarinic stimulation and alpha-2 adrenergic antagonism
- VUITY (Pilocarpine hydrochloride ophthalmic solution 1.25%, Allergan, an AbbVie company)1
- Phentolamine 0.75% (Opus Genetics) is currently under investigation for the treatment of presbyopia and has a PDUFA date of October 17, 2026.5,6
- All of the FDA-approved drops feature similar warnings of an increased risk of retinal traction, tears, and detachment with the use of miotics.1-4
- A dilated fundus examination is recommended in all patients prior to starting treatment.7 Patients should be advised to seek immediate medical care with the sudden onset of flashes of light, floaters, or vision loss.
Patient selection for presbyopia drops
Dr. Davison has successfully integrated presbyopia drops into her practice and noted that this is in part due to identifying motivated patients, such as those experiencing difficulties with their daily life activities due to presbyopia, because they need to be committed to putting in a drop on a regular basis.
Prior to prescribing a drop, she ensures that patients have a healthy retina with a dilated fundus examination and then takes a deep dive into their lifestyle, work, visual demands, and lighting situations.
Lighting is an important consideration as there are various drops with different concentrations, and some will constrict the pupil more than others, which she explained is important for those working in a dimly-lit environment.
Older patients naturally have smaller pupils in mesopic conditions and a certain level of compromise that may reduce the value of presbyopia drops,7 so early presbyopic patients ~40 to 55 years old are likely the ideal age for these drops Dr. Yackey explained.
Tips for screening patients for retinal disease
As one of the largest concerns with presbyopia eye drops is the potential risk for retinal detachment,8 Dr. Yackey recommended pairing dilation with color fundus photography to get a map of the patient’s retina health.
She also suggested performing scleral depression for these patients or to at least get a good look in the retinal periphery to ensure that no lattice degeneration (retinal thinning), holes, or breaks are noted prior to starting any presbyopia drops.
Recent efficacy and safety data on pilocarpine 0.4%
Dr. Yackey highlighted data from a recent study conducted at Bascom Palmer Eye Institute that compared the effect of pilocarpine 0.4% and 2% on three key responses in patients with early to moderate presbyopia:9
- Ciliary muscle response
- Pupil diameter
- Lens thickness
The study demonstrated that pilocarpine 0.4% significantly reduced pupil diameter and produced no significant changes in lens thickness or ciliary muscle movement relative to balanced salt solution (the control).9
Conversely, the pilocarpine 2% solution resulted in a statistically significant change in ciliary muscle movement at near not observed in the QLOSI or control groups, a residual lens accommodative effect also not reported for the other two groups, and a dose-dependent effect on pupil diameter.9
The significance of these findings? Aging patients (i.e., those most likely to be presbyopic) are at higher risk of preexisting retinal disease, so having a topical miotic that has demonstrated contraction of the ciliary muscle comparable to balanced salt solution (BSS) may lower the risk of developing peripheral retinal tears and detachments with use.
“While the Bascom Palmer study showed that QLOSI shouldn’t affect ciliary muscle contraction, it’s still important to highlight the need for screening because we don’t want anyone to go from seeing to not seeing just because we’re trying to make their life a little more convenient.”
Discussing potential side effects of presbyopia drops with patients
Dr. Yackey emphasized the importance of telling patients to contact the office if they see any new flashes, floaters, or any other visual abnormalities to promptly identify and address any potential adverse effects.
Dr. Davison explained that when she discusses the potential dimming effect of pilocarpine 0.4% with patients, she dims the lights in the exam room to illustrate what they can expect to experience. She added that in her personal experience, by the time the drop wears off, she hasn’t experienced a significant impact in her nighttime vision, but that is a conversation that is important to have with the patient so they’re aware and can plan accordingly.
For example, in her experience, a patient putting in the drop midday may report pupil constriction for up to 10 hours, so she asks patients when they plan to use the drops to ensure they’re comfortable driving home in the evening or can get home without driving if necessary.
Tips for implementing presbyopia drops
Dr. Davison recommended starting with drops that contain a lower concentration to minimize the risk of adverse events, which can include headaches, ocular hyperemia, and some dimming.2
As such, she typically starts with QLOSI, and for cases where starting with a low concentration may not be as effective, she moves to a drop such as VIZZ or potentially even the combination drop YUVEZZI. However, she first sets clear expectations by informing patients that there is a potential tradeoff of a stronger effect with a higher risk of side effects like headaches and redness.
In addition, Dr. Davison noted that another key step to success is getting the staff on board when implementing presbyopia drops so they can help with educating and triaging those patients accordingly.
“Know the risks, check the retina, and have a plan set in place with the practice staff.”
Key takeaways
- Identifying motivated patients and setting clear expectations are key to long-term success with presbyopia drops.
- A dilated color fundus examination with scleral depression is recommended for all patients to screen for retinal disease.
- Pilocarpine 0.4% has been shown to cause ciliary muscle contraction similar to BSS, potentially reducing the risk of retinal traction, tear, and detachment.8
- Using the lights in the exam room can be a helpful way to illustrate the dimming effect of presbyopia drops.
- It is helpful to weigh the different concentrations and durations of presbyopia drops to match patients’ needs closely; drops with a longer treatment effect may require patient education on avoiding night driving.
Conclusion
The growing list of presbyopia-correcting drops signals the importance of providing eyecare to patients that is convenient, safe, and tailored to their lifestyle needs.
Dr. Davison emphasized that these drops will not be the end of reading glasses or glasses in general—they’re a tool—and having another option in the toolbox provides flexibility for the growing population of patients with aging eyes.
