As of October 2021, there is now a topical treatment for presbyopia: Vuity (pilocarpine HCl ophthalmic solution 1.25%), Allergan’s daily prescription eye drop recently approved by the FDA. Vuity is the first eye drop to treat presbyopia; while there are many existing management strategies, Vuity is the first to leave behind corrective lenses or surgical intervention.
“Presbyopia is such a common condition that our optometry colleagues and many of us ophthalmologists encounter it on a day-to-day basis in clinical practice,” said Nandini Venkateswaran, MD, a fellowship-trained cataract, cornea, and refractive surgery specialist at the Massachusetts Eye and Ear Infirmary, “Vuity, as the first presbyopia-correcting eye drop, is really going to be a game-changer for the landscape of presbyopia.”
We interviewed optometrists and ophthalmologists to find out what doctors think about the Vuity eye drop for presbyopia. Keep reading to learn more about this exciting new development in pharmaceutical technology!
What is Vuity used for?
Presbyopia is an extremely common condition, affecting an estimated 1.8 billion people worldwide. Nearly 128 million people in the US, or just under half of US adults, are believed to be presbyopic.
Defined as a loss of accommodative ability, the symptoms of presbyopia most commonly include blurred vision at near, squinting, and headaches. While the exact mechanism of presbyopia is unknown, two main theories exist: first, that presbyopia is an artifact of lens aging, and second, that presbyopia is related to muscle dysfunction or other extralenticular causes.
Until this year, presbyopia management strategies were confined to corrective lenses—glasses and contacts—and surgical intervention. With the approval of Vuity, management strategies now include topical treatments.
How does Vuity work?
Vuity is a miotic drop, which means it causes a pinhole effect by making the pupil contract. This mimics the eye’s natural ability to focus, allowing for greater vision at near in presbyopic patients.
Pilocarpine HCl ophthalmic solution 1.25%, the active ingredient in Vuity, acts as a muscarinic receptor agonist. Eyecare practitioners will recognize pilocarpine as a common medication used to lower IOP, constrict pupils following dilation, and treat aqueous deficient dry eye.
What are the side effects of Vuity?
Known adverse side effects from the GEMINI 1 and 2 studies include headaches and eye redness.
How long does Vuity last?
Vuity takes effect in 15 minutes and lasts up to 6 hours.
How will Vuity impact patients?
“Our patients have not really had any options for the treatment of presbyopia, besides just dealing with it or wearing bifocals, progressives, or even contact lenses,” said Dr. Venkateswaran.
Dr. Venkateswaren added, “Vuity is going to provide clinicians with the opportunity to not only address presbyopia as a condition, straightforwardly in the clinic, but then also offer a solution: 'Here's an eye drop that's easy to use, that's easy to access, and will allow you to live a more functional lifestyle without always depending on your glasses or readers, if you are a good candidate.' ”
Alanna Nattis, DO, FAAO, a refractive cornea surgery specialist at SightMD, agreed: “Our practice, like many other busy ophthalmic practices, sees and treats a large number of patients with presbyopia. Up until the possibility of offering a pharmacologic treatment, we were relegated to recommending reading glasses (and different permutations of such—bifocals, progressives), monovision and multifocal contact lenses, as well as laser vision correction and even clear lens exchange surgeries in some cases. While these are all viable options and many have proven their value as treatment strategies over time, there is something that seems really easy and significantly less disruptive about using an eye drop to treat presbyopia for these patients.”
Many patients find it burdensome to need reading glasses, particularly if they have not needed corrective lenses until this point. Even those for whom contact lenses are an option find the change in their vision disruptive. While surgical options for presbyopia are available, like all surgeries they are more invasive.
“Many patients are looking for a non-glasses option for their presbyopia and our current options with contacts often require some kind of compromise in vision and/or comfort, and just simply aren’t a realistic option for many people, and options in glasses (progressives, single vision distance/near, separate computer pair, etc.) have their own compromises as well,” said Sathi Maiti, OD, an ocular surface disease fellow at the Periman Eye Institute. “If Vuity works well it could be a game-changer in terms of how we treat presbyopia. As eye doctors, because it is so common I think a lot of the time we forget how much presbyopia really impacts the quality of life of many of our patients, and this is a type of solution that many of them might be seeking out.”
Who will Vuity be best for?
Dr. Maiti said that many of her presbyopic patients will likely be interested in trying the drug.
“It will likely work best for those who don’t have very precise vision needs and are okay with some compromise or fluctuation in clarity,” she points out. “Since I haven’t had the chance to see how it works in real life yet, it’s a little hard to say, but my best guess would be for early presbyopes who don’t need super high adds yet.”
Dr. Nattis agreed. “I believe the drop will have the strongest effect on early presbyopes with minimal refractive error. That being said, I do think there is room for use of this drop in patients who prefer to wear distance-only and reading-only spectacles or contact lenses.”
Like any prescription medication, of course, Vuity might not be appropriate for all patients.
“I do not believe this eye drop will be as efficacious for patients who have advanced presbyopia, nor those with relatively dense cataracts,” added Dr. Nattis. “In the case of the cataractous presbyope, refractive cataract surgery may still be the best answer for these patients. However, there is an interest in research moving forward regarding the use of this eye drop in patients undergoing cataract surgery with monofocal IOL implantation. Here, the pinhole effect induced by Vuity could help provide a wider range of vision in this group of pseudophakic patients.”
Dr. Maiti believes that Vuity might not be as useful for those of her patients with high adds or those who need to see very fine detail at near. Additionally, those who would be frustrated by blur or fluctuation in their vision throughout the day might find Vuity a poor management strategy.
“I’m also curious to see if initial pupil size will impact how well it works for patients, like if those with already pretty miotic pupils or those with naturally larger pupils will notice much improvement,” she said. There are other concerns for her as well. “Given that I work in a dry eye clinic, we always have some concern for patients using drops with BAK as a preservative as it is known to cause ocular irritation and can contribute to ocular surface disease. Since Vuity does have BAK, that would be something we would want to take into consideration for our patients with dry eye, and we may only recommend it for occasional use versus daily use.”
How will Vuity impact refractive surgery practice?
Dr. Nattis and Dr. Venkateswaran are very interested to see how this will impact their refractive surgery practice. As Dr. Venkateswaran noted, many ophthalmologists want to offer their patients solutions for presbyopia, but don’t always want to dive into surgical intervention when their patients only find their reading glasses mildly frustrating. Topical medications like Vuity offer non-invasive management strategies that could satisfy both parties.
Dr. Nattis sees multiple avenues for the incorporation of Vuity into refractive surgery practice: “First, presbyopic emmetropes who previously underwent laser vision correction (LVC) may not need to wear readers as much—and may not seek out monovision enhancement surgery to help improve their near vision. Vuity may be able to provide this service instead!”
It also may allow surgeons to feel more comfortable offering LVC to early presbyopes, she said, especially knowing that this eye drop can help improve near vision post-surgery.
For Damon Dierker, OD, FAAO, who practices at Eye Surgeons of Indiana, Vuity is poised to be what he called a great “gateway” medication. “As patients’ presbyopia continues to progress, at some point they will be ready for either cataract surgery or even refractive lens exchange,” he said. “When that time comes, I predict that patients relying on pharmacotherapy to manage their presbyopia will likely be very interested in presbyopia-correcting and light adjustable IOLs.”
How will Vuity impact glasses prescriptions?
If Vuity works well in practice, Dr. Maiti thinks that fewer patients may look to buy contact lenses or progressives for their presbyopia. “However, I think it is most likely people will end up still needing some kind of eyeglass or contact lens correction, especially given that Vuity was only shown to work for 6 hours,” she said.
“Even if people do use it, they will probably still need some type of reading prescription for the end of the day or days they choose not to use Vuity. It may also end up being something patients use in combination with glasses for their presbyopia, such as wearing their glasses when they require sharp near vision at work, and using Vuity for when they go out, on vacation, or are just at home and don’t need as clear near vision.”
How will Vuity impact eyecare practices?
Dr. Venkateswaran is excited to bring Vuity into her practice. “I think that many of us clinicians have often avoided the conversation of presbyopia in our clinics because we don't necessarily have a great solution for it,” she said. “And now we can bring it up and offer patients the opportunity to treat it. That's going to increase practice volume and growth for ourselves as well as for our optometry colleagues.”
“Being a new, exciting, and easy-to-use technology, I believe Vuity will be something we will be eager to offer our presbyopia patients—and that sooner rather than later, patients will be coming in, asking to trial the drop,” said Dr. Nattis. “The nice thing is that the drop is easy to use (infrequent dosing), has a good safety profile, and its effect can be reversed (if need be) after simply stopping its use.”
Dr. Dierker agreed and added that Vuity’s broad label makes it an exciting prospect. “I’m not sure that anyone is certain as to whom the early adopter patients will be,” he said. “I think patients will appreciate having more options to treat their 'blurry near vision.' For many, I see this as being an add-on to existing strategies to treat presbyopia.”
Still, for many doctors, there are questions yet to be answered, as Vuity begins to roll out in eyecare practices.
“Will there be samples available that we can give to patients? Or will we just have to prescribe it and see? Cost will certainly also be a factor, as I don’t think anyone knows yet how much it will cost to patients and if it will be covered by insurance. I think many doctors are wondering how we will bill for it as well,” said Dr. Maiti. “It will definitely be interesting to see how we incorporate it into practice.”
Furthermore, Dr. Maiti pointed out, as a prescription drop with potential known side effects, office visits will be more complex than they would be with a simple glasses prescription. Doctors and patients will want to be clear on whether it fits into the standard vision exam or should require follow-up.
Overall, however, the tone is one of excitement: a new addition to the doctor’s armamentarium means more opportunities to offer patients the solution to their presbyopic vision problems.
“I'm super excited to see how this drop works in our patient populations and what the patient feedback and reception are,” said Dr. Venkateswaran. “Ultimately, I believe this is going to be a really revolutionary technology in the ophthalmic space.”