The information in this article was updated July 2026. Original article authored by Cecelia Koetting, OD, FAAO, Dipl. ABO and Jai Parekh, MD, MBA, FAAO. Updates provided by Harmin Chima, OD, FAAO. Clinical review performed by Natalie Osayande, OD, MS.
Despite all the advances in pharmaceutical eyecare over the years for a myriad of eye conditions, including glaucoma, dry eye, and ocular allergy, presbyopia has stood out as a significant unmet need.
With the entry of the first pilocarpine drop for presbyopia in October 2021 and a slew of other companies following suit in the presbyopia race over the next several years, patients finally have hope.
Presbyopia usually affects folks around age 40, progressively worsens, and continues to evolve every decade until age 100. Activities of daily living (ADLs), including reading, surfing iPads, perusing nutritional labels, and texting, can be greatly impacted in presbyopic patients.
Before this first pharmaceutical approval, the only options for patients included progressive addition lenses (PALs), multifocal contact lenses, over-the-counter (OTC) reading glasses, and surgical solutions.
Overview of presbyopia prevalence and classification
It is reported that over 1 billion people worldwide have presbyopia, with treatment burden alone costing well over $31 billion.1 In patients under the age of 50 with presbyopia (which internationally represents nearly 245 million working-age presbyopes), this refractive error led to over $11 billion in annual productivity loss.1
As presbyopia was rarely discussed at national meetings until recently, it was not even classified. Recently, a panel of ophthalmologists and optometrists led by Marguerite B. McDonald, MD, convened to do just that—suggest a way to classify presbyopia.
The authors proposed the following:2
- Mild presbyopia: <1.25D of add power
- Moderate presbyopia: between ≥1.25D and +2.00D add power
- Advanced presbyopia: ≥2.00D of add power
Mechanism of action of presbyopia drops
It helps to understand the mechanism of action and differences between the presbyopia drops in order to better manage expectations and who may benefit from each drop. All drops are pupil-modulating with varying degrees of ciliary muscle engagement. Qlosi stands apart as the only drop with Bascom Palmer-published data showing ciliary muscle movement comparable to BSS (balanced salt solution).
The pinhole effect is a method of pseudoaccommodation via miosis and pupil size reduction without ciliary muscle engagement, working to increase the depth of field while avoiding distance vision loss. Xu et al. studied pupil size as it relates to photopic, mesopic, and scotopic conditions, finding that as the pupil size decreased, there was an increase in reading vision improvement.3,4
However, if the pupil was too small, the patient began to lose contrast and lines of near vision. The researchers reported that there is a “sweet spot” at 30% miosis from the patient’s natural pupil size.3
Download the cheat sheet here!
Presbyopia Pharmacologic Drop Comparison Table
Use this cheat sheet to compare the dosing, performance, tolerability, and patient selection for presbyopia drops to help match patients with the optimal drop for their specific needs.
Currently available presbyopia drops
QLOSI (Orasis Pharmaceuticals) utilizes a low dose, preservative-free ophthalmic solution of pilocarpine HCl 0.4%, a cholinergic agonist indicated for the treatment of presbyopia in adults.5 The medication was approved by the FDA in October 2023 for daily or up to twice each day administration and launched in the United States commercial market on April 7th, 2025.
With a preservative-free near-neutral pH formula that contains lubricating agents, it has been designed to provide flexible dosing with the option to dose a second time if needed 2 to 3 hours after the initial dose, extending the potential efficacy from 20 minutes after administration to up to 8 hours.6
Clinical data from the Phase 3 NEAR-1 and NEAR-2 trials demonstrated that efficacy improves with consecutive daily use. The proportion of patients who achieved 20/40 or better near vision rose from 74% on Day 1 to 89% on Day 8. Approximately 40.1% of patients treated with QLOSI achieved a 3-line or better gain in mesopic (low-light) near vision by Day 8.7
QLOSI was well tolerated and is the only miotic in the class with no single adverse event percentage over 10%. The most common TRAEs were headache (6.8%) and instillation site pain (5.8%).7
A prospective, single-center, head-to-head study done at the Bascom Palmer Eye Institute in Miami showed QLOSI had no significant impact on lens thickness and ciliary muscle accommodation in presbyopic eyes, further proving the safety of using this drop for presbyopia management.8,9
YUVEZZI
YUVEZZI (Tenpoint Therapeutics) is a preservative-free (PF) combination ophthalmic solution of carbachol 2.75%, a miotic agent for pupil constriction, and brimonidine tartrate 0.1%, which inhibits iris dilator muscle contraction.10
Brimonidine is also believed to possibly inhibit ciliary muscle contraction, thereby assisting to decrease associated side effects, as well as act as a vasoconstrictor leading to increased bioavailability and duration of action of the carbachol molecule.10
Phase 3 pivotal BRIO-I trial met its primary endpoint, achieving >15 letter gain in binocular DCNVA without a loss of ≥5 letters at distance, starting at Hour 1 and maintaining across all time points through Hour 8. The drug was well-tolerated by trial subjects, with no significant adverse events.11
The most notable reported TRAES were headache (15.6%), eye irritation upon instillation (14%), eye pain upon instillation (6.7%), and visual impairment (6.4%).12
VIZZ
VIZZ (aceclidine 1.44%, LENZ Therapeutics) leverages the novel active ingredient aceclidine, which targets the iris sphincter muscle to promote pupil constriction while avoiding overstimulation of the ciliary muscle and resultant myopic shift.13
In the CLARITY 2 trial, VIZZ achieved all primary and secondary endpoints. With 95% of participants achieving >2 lines near vision improvement and 73% >3-line near vision improvement after 1 hour.14 Additionally, 93% of participants achieved 20/40 or better near vision at 30 minutes and lasted up to 10 hours.14
VIZZ was well tolerated with no serious TRAEs reported, and most adverse events were mild and temporary. The most common reported TRAES were instillation site irritation (20%), dim vision (16%), and headache (13%).13
VUITY
VUITY (pilocarpine HCl 1.25%, AbbVie) was the first FDA-approved topical drop to pharmacologically treat presbyopia. In March 2023, it was approved by the FDA for a twice-daily dosing option along with its original approval as a once-daily treatment obtained in October 2021.15 Dosing at either QD or BID, the second dose may be administered 3 to 6 hours after the first, extending the duration of effect of VUITY for up to 9 hours.16
The phase 3 VIRGO trial that led to BID dosing approval met the primary endpoint proportion of participants required that gained ≥3 lines in mesopic, high contrast, binocular distance corrected near visual acuity (DCNVA), with no more than 5-letter loss in low light corrected distance visual acuity (CDVA) at Day 14, Hour 9 (3 hours after the second drop) versus placebo.16
The most common adverse reactions reported in >5% of participants were headache and eye irritation. Ocular adverse reactions reported in 1 to 5% of participants were visual impairment, eye pain, blurred vision, and vitreous floaters. No reports of retinal detachment were found during the trial.16
Note: The brand-name formulation of VUITY has been discontinued.
Presbyopia drop pipeline
Phentolamine 0.75%
Phentolamine 0.75% (Opus Genetics and Viatris) works as a non-selective alpha-1 and alpha-2 adrenergic antagonist.16 It inhibits alpha-1 adrenergic receptors on the iris dilator muscle, thereby decreasing pupil size through a sympatholytic mechanism that minimizes involvement of the ciliary muscle.
This approach may reduce the risk of complications such as retinal tears or detachment that can occur with parasympathomimetic agents.16 The VEGA-2 and VEGA-3 trials demonstrate encouraging positive efficacy results for this non-invasive treatment for presbyopia, successfully achieving all primary and key secondary endpoints without any serious adverse events related to the treatment.16
Currently, RYZUMVI is FDA-approved for managing pharmacologically induced mydriasis caused by adrenergic agonists (such as phenylephrine) or parasympatholytic agents (like tropicamide). For the presbyopia indication, the FDA has accepted a Supplemental New Drug Application, with the Prescription Drug User Fee Act (PDUFA) target date set for October 17, 2026.16
In February, the FDA cleared Cloudbreak Pharma’s IND application for CBT-199, an investigational topical ophthalmic emulsion under clinical development for presbyopia. Check out this Glance story to learn more about the candidate!
A rundown of presbyopia drops
With multiple presbyopia-correcting drops currently available and in the pipeline, it is important to set the stage for their use. The addition of a whole new category to the treatment of presbyopia is revolutionary and broadens the therapeutic management playbook for both practitioners and patients.
With this thought in mind, it will require ECPs to adjust patient education and prescribing patterns. The great news is that ophthalmic medications are a familiar modality to both patient and practitioner, which could lead to earlier adoption.
As discussed, some of the formulations are actually reformulations of previously approved medications coupled with innovative drug delivery platforms, while others are novel drugs. This could be considered a seminal moment for ECPs to offer a new treatment that may help to improve the patient’s quality of life, both from a visual and a psychological standpoint.
As will be discussed, it is imperative to set realistic expectations (including limitations) and the overall reality when it comes to treatment. It is similar to multifocal contact lenses or intraocular lenses (IOLs) pertaining to patient education and discussion: underpromise, overdeliver, and be prepared to pivot.
Short on time? Download the Presbyopia Pharmacologic Drop Comparison Table!
Presbyopia drop practice implementation
One of our primary jobs as ECPs is to continue to educate ourselves on the newest treatment options and present them to appropriate patients. Pharmacological treatments for presbyopia are just that: a new opportunity to treat our patients' near vision problems.
Similar to how we present other options to patients, we have to think about what will work best for those who might be in the chair—whether it be progressive or bifocal glasses, multifocal or monovision contact lenses, and/or presbyopia-correcting drops. Oftentimes, it is a combination of these therapies. Like different pairs of shoes for different occasions.
It is imperative to remember that these drops are not replacing glasses and contact lenses with the perspective that they are a complementary therapy to what is already available. A multicenter optometric practice set out to answer the question of whether or not miotics would cannibalize optical sales. After concluding a pilot program using QLOSI across multiple offices, the practice found that there was no detrimental effect on optical conversion in their patients who tried QLOSI.17
This finding was pivotal in disproving the myth that presbyopia drops will hurt optical sales. As more presbyopia drops enter the market, ECPs will have to think about patient selection with thought given to activities of daily life and the level of the patient's lens dysfunction journey.
Involving staff in the process of evaluating presbyopic patients
Depending on the flow of your office, it can be helpful to engage your staff in this discussion and once again reinforce patient selection. Implementing an ADL questionnaire before the exam or at check-in may be helpful to find where the patient is having difficulties with vision and open up discussion.
Staff can use this to gather more information regarding computer and reading distances, identifying which patients may be struggling with their current solutions or lack thereof.
If the staff has been empowered to routinely dilate patients prior to being seen by the ECP, make sure that they are checking the patient’s pupil size in both mesopic and scotopic conditions. As discussed earlier, pupil size is an important piece of data when considering who will benefit from utilizing presbyopia drops.
To download staff scripts about presbyopia drops, check out the article Insights into Improvements in Pilocarpine for Presbyopia!
Providing patients with a trial run of presbyopia drops
Trialing the drop in-office may work in some instances, but not all. Since it is recommended that patients receiving presbyopia-correcting drops undergo a dilated fundus exam prior to prescribing, same-day trialing is unlikely.
A single use of the drop is also not a true representation of how the medication will work for the patient. QLOSI requires a “clear start week” which allows the patient to neuroadapt, and eventually achieve near acuity of 20/40 as seen in the trials. With VUITY, many patients experience a ciliary spasm with the first usage and up to 2 weeks for certain patients. VIZZ often requires multiple days of use for side effects to improve.
Because of this and for other reasons, it is better to educate the patient in the office on what to expect and then send them home with a prescription to use every day for a set amount of time to truly understand if the medication will work for them given their history and case presentation.
Examples of in-office discussions with a presbyopic patient
ECP: “Patient XYZ, based on our discussion, I think that this particular presbyopia-correcting drop will be very helpful. It works by constricting your pupils and increasing your ability to see up close, while not affecting your distance vision.
Now, there are multiple drops that could achieve this visual balance, but in my professional medical opinion, I believe this particular one will work best for you. If, for some reason, it doesn’t, don’t worry; we will try another, very similar to how we work together to land on the right contact lens fit for your vision and overall comfort.
When you go home today, I would like you to start tomorrow by using this drop every day for the next 2 weeks.”
Patient: “Is there anything I should expect after first using the medication? What about side effects?”
ECP: “During the first few uses, you may feel like your vision is going a little 'wonky,' this is normal it is your muscles may contract. For the initial 2 weeks, you may have slight frontal headaches, which we have come to understand is rather normal because we are working the muscles in your eyes differently than they have been in the past.
Similar to working out a new muscle at the gym, it will stop being sore with continued use. Over the next month, until I see you at the follow-up, pay attention to how this is working for you and in what situations you are finding it helpful or when it is not working well. When you come back, we can discuss this and the next steps if needed.”
Best practices in presbyopia pharmacological management
As the presbyopia landscape continues to evolve since the launch of the first presbyopia-correcting treatment in 2021, organizations like the FDA and the American Society of Cataract and Refractive Surgery (ASCRS) have weighed in with guidelines for practitioners to help guide their prescribing habits.
The ultimate conclusion is that an ECP-led delivery model for presbyopia treatment is essential. Patients need to be assessed for their gaps in presbyopia care (i.e., lifestyles), and every patient is required to have a full eye exam, including a refraction update as well as anterior and posterior segment surveillance.
Any patient with a history of high myopia, known recurrent ocular inflammatory diseases (i.e., uveitis), potential narrow angles, or peripheral retinal disorders at risk for the development of retinal detachment (RD), including lattice degeneration and/or retinal holes, should be advised against topical presbyopia therapies.
Since these guidelines have evolved and ECPs have learned how to carefully select patients for pharmacological presbyopic treatment, the overall incidence of retinal issues seems to have abated. It would behoove the eyecare practitioner to start with the lowest concentration drop (QLOSI [0.4% pilocarpine]) given its highest tolerability. If the patient is not satisfied with the visual outcome after sufficient time is allowed for neuroadaptation, the practitioner can then move on to a stronger option.
Note: If a patient were to experience flashes, floaters, or visual field loss (i.e., “curtains”) after administration of a presbyopia-correcting therapy, it is strongly recommended to seek the care of an ECP immediately to address these complaints.
Conclusion
Confidence in patient outcomes is based on individual case presentation, lifestyle needs, identifying the right candidates, managing expectations, conducting a thorough eye exam, and scheduling appropriate follow-up.
These are the keys to success for topical presbyopia therapy as this exciting landscape continues to progress and we learn more.
