Addressing presbyopia pharmacologically

April 24, 2012

Monocular treatment of the non-dominant eye by instillation of pilocarpine or carbachol, both cholinergic agonists, and bromonidine (Alphagan-P, Allergan), an alpha agonist that can prolong the effect of cholinergic agonists, might be a new approach to treating presbyopia. Steve Kaufman, MD, PhD, described this potential treatment during the Innovators' Session.

Chicago-Monocular treatment of the non-dominant eye by instillation of pilocarpine or carbachol, both cholinergic agonists, and bromonidine (Alphagan-P, Allergan), an alpha agonist that can prolong the effect of cholinergic agonists, might be a new approach to treating presbyopia. Steve Kaufman, MD, PhD, described this potential treatment during the Innovator’s Session.

This technique is based on creating a pinhole effect pharmacologically in the non-dominant eye; the resultant vision in the eye is clear although a bit dimmer. The vision in the fellow eye with the normal pupil might have some blurry near vision, but distant objects are clear and there is no diminished light perception.

“When the images are merged, most people have clear focus at near and distance with no diminished light perception and dimness,” said Dr. Kaufman, director of cornea and refractive surgery, Elias Potter Lyon Chair for Research in Ophthalmology, University of Minnesota, Minneapolis.

Dr. Kaufman and his colleagues tested commercially available concentrations of pilocarpine and bromonidine, pilocarpine alone, and carbachol in various concentrations with and without bromonidine compared with placebo (artificial tear). One dose of the drugs tested was put in the non-dominant eye of 12 subjects to determine if the reading vision was corrected without blurred distance vision as with a monofocal IOL or dimness. There was a washout period between the different treatments. The near and distance visual acuities were measured 1, 2, 4, and 8 hours after instillation of the drugs.

“The optimal concentration of pilocarpine was 1%, which provided the greatest duration of reading vision,” he said. “In the pilocarpine alone group, the near vision improved 2.3%. Pilocarpine with brominodine improved the near vision to J3. The optimal concentration of carbachol was 3%, which amazingly resulted in a 6.3-line improvement in near vision; this requires a larger study. We also found that brominodine potentiated the effects. Carbachol and brominodine can be used once daily to achieve an 8-hour effect.”

Minor discomfort was reported by 10% to 30% of patients.

When asked if they would use this treatment if it were available, 90% of patients responded positively.

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