Presbyopia is an age-related refractive condition that gradually diminishes the eye’s ability to focus on near objects. It typically begins in the early to mid-40s and affects nearly 1.8 billion people worldwide. In the United States alone, an estimated 128 million people, nearly 90% of adults over age 45, are impacted.1
As our worlds continue to inch closer and closer and screen time increasingly dominates our daily routines, near vision clarity is more important than ever. Fortunately, optometrists are uniquely positioned to provide tailored, effective solutions.
An overview of presbyopia
Presbyopia results from age-related changes in the crystalline lens and ciliary muscle function. Over time, the lens becomes less flexible and loses its ability to change shape, while the ciliary muscles lose their elasticity, resulting in decreased ability to accommodate to near stimuli. In short, presbyopia is the loss of ability to focus on objects that are close to you.2
Common presbyopia symptoms include:
- Blurry near vision
- Eye strain/fatigue and/or headaches during or after prolonged periods of reading/close work
- The need to hold reading material further away (when your arms just don’t feel long enough!)
Other factors can contribute to the onset and symptoms of presbyopia, such as:3
- Systemic conditions
- Diabetes: Long-term hyperglycemia alters the composition of the lens, leading to increased rigidity and reduced accommodation at an earlier age.4
- Cardiovascular disease: Compromises circulation to the ciliary body and lens, impairing the metabolic function of the ciliary muscle.5
- Medications: Antidepressants, antihistamines, and diuretics can accelerate the onset of lens changes and therefore presbyopia.3
- Screen time: Consistent screen exposure exacerbates near vision strain.
- Environmental/lifestyle influences: Inadequate lighting, reduced blink rate from prolonged screen time, poor sleep, and poor ergonomics can exacerbate symptoms.
Treatment evolution: past and present
Historically, the most straightforward approach to managing presbyopia was through single vision reading glasses. As needs evolved, so did optical solutions, progressing to bifocal and progressive addition lenses that offer easy transitions between distance and reading all in one pair of glasses.
For contact lens wearers, monovision and multifocal designs provide functional near and distance vision without relying on spectacles. Today’s treatment landscape includes not only glasses and contact lenses, but also pharmaceutical drops, laser procedures, and intraocular implants, each offering customized visual solutions based on patient needs and lifestyle.
Pros and cons of current presbyopia treatment options
Table 1: Pros and cons of established presbyopia treatments.
| Treatment | Pros | Cons |
|---|---|---|
| Single vision reading or intermediate (computer) glasses | Generally low-cost, non-invasive, and effective for task-specific correction | Only useful for near tasks, must be removed for distance, and does not address intermediate vision needs |
| Bifocal lenses | Corrects both near and distance in two distinct optical zones in one pair of glasses | Abrupt transition can cause visual discomfort, there is no intermediate zone, and cosmetically unappealing line |
| Progressive addition lenses (PALs) | Provide a gradient of power for seamless visual transition between all distances, more cosmetically appealing, and easily customizable to lifestyle needs | Requires adaptation period, peripheral distortion in parts of the lens, and generally more expensive than other spectacle lens options |
| Monovision contact lenses | One eye is corrected for near and the other for distance, eliminates need for spectacle correction, and cost-effective using standard lenses | Possible reduced depth perception, potentially difficult adaptation period, and may not be suitable for certain visual demands |
| Multifocal contact lenses | Offers simultaneous near and distance correction within each lens, both eyes are working together, and eliminates need for spectacle correction | Not all patients achieve clear vision at all distances, adaptation period required, potential difficulty in low light conditions, and presently limited options for patients with astigmatism |
Table 1: Courtesy of Erica Meltzer, OD.
Newer presbyopia treatments
Table 2: Key characteristics of recent presbyopia therapies.6-9
| Treatment | Mechanism of Action | Pros | Cons | Potential side effects |
|---|---|---|---|---|
| VUITY (pilocarpine 1.25%, Allergan, an AbbVie company) | Enhances near vision by inducing pupillary miosis, thus improving depth of focus | Non-invasive topical eye drop and quick onset of action | Effects are temporary, requires multiple doses, not ideal for patients with retinal or optic nerve conditions, and elevated risk for retinal detachment | Headache, brow ache, eye redness, and may cause night vision issues |
| QLOSI (Pilocarpine HCL 0.4%, Orasis Pharmaceuticals) | Works similarly to VUITY by inducing miosis and increasing depth of focus through contraction of the iris sphincter muscle | Fast onset (15 minutes), flexible dosing, and lowest effective concentration of pilocarpine | Short duration compared to VIZZ and variable effectiveness in dim lighting | Headache, brow ache, eye redness, and dim low-light vision |
| VIZZ (Aceclidine 1.44%, LENZ Therapeutics) | Induces miosis through selective muscarinic receptor activation, increasing depth of focus without significantly affecting distance vision | Smaller and more stable pupil compared to pilocarpine, longer duration of action (6 to 8 hours), reduced night vision impact, and fewer headaches | Temporary blurred distance vision and mild ocular discomfort | Eye redness, mild burning, and brow ache |
| PresbyLASIK | Uses excimer lasers to create multifocal corneal zones | Corrects presbyopia and other refractive errors (myopia, hyperopia), immediate and long-lasting results, and customizable to individual patient needs | Permanent, non-reversible corneal alteration, limited long-term stability data, and not recommended for patients with thin corneas or dry eye disease | Glare, halos, and other visual disturbances |
| Conductive keratoplasty | Applies radiofrequency energy to reshape the cornea | Minimally invasive and does not remove tissue | Regression over time is common, less precise than laser alternatives, and largely declined in clinical use due to limited precision and durability | May induce irregular astigmatism or alter distance vision |
| Monovision LASIK/PRK | Corneal laser reshaping to achieve monovision (one eye corrected for distance, the other for near) | Provides spectacle independence for many daily tasks, adjustable based on patient dominance and needs, and reversible in some cases via enhancement | Reduced depth perception, may cause imbalance or visual discomfort, requires neuroadaptation | Dry eye, glare, halos, or reduced contrast sensitivity, and potential for regression over time |
| Monovision ICL (Implantable Collamer Lens) | Implantable lens placed in front of the natural crystalline lens to achieve monovision correction | Suitable for patients with thin corneas or high refractive errors, reversible (lens can be removed or exchanged), predictable outcomes with stable refraction | Requires intraocular surgery, potential for anisometropia or adaptation difficulty, and higher cost | Cataract formation, elevated intraocular pressure, glare, halos, or dysphotopsias |
| Multifocal intraocular lenses (IOLs) | Offer multiple focal points to restore range of vision | Provide near, intermediate, and distance vision and can reduce or eliminate the need for glasses | Not all patients adapt well and higher out-of-pocket costs | Glare, halos, and reduced contrast sensitivity |
| Accommodating IOLs | Mimic the eye’s natural accommodative mechanism by shifting position or changing shape in response to ciliary muscle activity | Fewer visual disturbances (halos, glare), mimics natural accommodation, and better contrast sensitivity | Variable patient outcomes, limited FDA-approval, and questionable long-term efficacy | Glare, halos, lens decentration, capsular fibrosis, and mechanical failure over time |
Latest clinical research and pipeline presbyopia therapies
Recent clinical research continues to advance presbyopia care by refining current therapies and exploring future breakthroughs. A 2023 Ophthalmology study confirmed that VUITY improved near visual acuity in patients with early-to-moderate presbyopia, with manageable side effects including brow ache and ocular hyperemia.6
Since then, two additional miotic-based treatments have gained FDA approval: VIZZ (aceclidine 1.75%) and QLOSI (pilocarpine HCl 0.4%), both of which offer non-surgical options for patients seeking temporary near vision improvement.
Additionally, several pipeline therapies are advancing clinical development. Viatris has announced positive phase 3 trial results for a novel, next-generation miotic agent with improved comfort and duration.10 Tenpoint Pharma recently submitted a New Drug Application for a carbachol/brimonidine tartrate combination aimed at enhancing near vision and contrast while minimizing side effects.11
Advancements in surgical treatments for presbyopia
A recent review showed favorable long-term outcomes for corneal inlays like KAMRA and RAINDROP, though complications such as haze and explantation remain concerns.8 Additionally, small-aperture IOLs like the IC-8 Apthera demonstrate promise by leveraging a pinhole effect to enhance depth of focus with reduced glare.12
Beyond pharmaceuticals, ongoing research into lens-softening technologies, corneal inlays, and regenerative medicine continues to expand the future scope of presbyopia therapy. Femtosecond laser lens-softening aims to restore flexibility to the aging lens, improving accommodation at the biomechanical level.13
Next-generation corneal inlays are being designed with enhanced biocompatibility and reversibility, while early studies in gene therapy and stem cell applications explore ways to rejuvenate or regenerate accommodative tissue.14
Product recalls and litigation
With innovation comes risk, and some presbyopia interventions have faced scrutiny or legal action:
- VUITY: While not recalled, VUITY has been associated with side effects including brow ache, eye redness, and transient blurry vision. Post-market surveillance is ongoing.6
- RAINDROP Near Vision Inlay: Recalled in 2019 due to corneal haze in a subset of patients. The explant rate and risk profile led to its withdrawal from the market.15
- KAMRA Inlay: Still in use outside the US, though discontinued domestically due to inconsistent outcomes and risk of corneal thinning or haze.16
Conclusion
Presbyopia remains one of the most common, yet evolving, challenges in optometric care. As the global population continues to age and as digital dependence increases, the demand for functional near vision will only intensify.
From simple readers to stem cell therapies, the spectrum of treatment options is broader than ever. While traditional optical corrections remain the standard of care, emerging pharmaceutical and surgical therapies offer patients new levels of freedom and quality of life.
Optometrists and eyecare professionals must stay informed, critically evaluate new technologies, and co-manage with surgical colleagues to provide personalized, evidence-based care.
Ultimately, the goal of presbyopia care is not just sharper near vision but preserving patients’ independence, confidence, and quality of life. With 20/20 foresight, the future of presbyopia care is within reach.
