CIME 2025: Neda Shamie, MD, on expanding options in pharmacological presbyopia management

At the recent Controversies in Modern Eye Care meeting, Neda Shamie, MD, offered valuable perspective on the evolving role of pharmacological treatments for presbyopia, describing them as a long-anticipated advancement in the field of ophthalmology. With presbyopia affecting nearly every patient over the age of 45, the demand for non-invasive, practical solutions is only growing.

Shamie emphasized that while traditional options—such as reading glasses, monovision contact lenses, and refractive surgery—remain effective, they do not serve every patient equally well. There exists a distinct population of emmetropic individuals in their mid-40s to mid-50s who have historically enjoyed excellent uncorrected vision and are now facing early presbyopic symptoms. For this cohort, pharmacological therapies present an ideal, complementary bridge before more invasive interventions become necessary.

Historically, 1.25% pilocarpine has been the mainstay of presbyopia drops. While effective for many, its higher concentration has posed tolerability challenges, particularly in terms of side effects such as headaches, brow ache, and reduced night vision. However, recent developments are addressing these limitations.

Shamie highlighted the recent FDA approval and clinical availability of a new formulation: pilocarpine 0.4%. This lower concentration retains the efficacy of its predecessor but offers a significantly improved side effect profile. More notably, the drop includes a vehicle designed to soothe the ocular surface, addressing concurrent ocular surface disease, which frequently contributes to visual complaints in this age group.

“This new drop is really a two-in-one solution,” Shamie remarked. “It delivers the visual benefit of pilocarpine while also supporting ocular surface health, which is often compromised in this demographic.”

The arrival of this new formulation expands the toolkit for presbyopia management and underscores the importance of individualized patient care. As the field continues to explore next-generation pharmacological options, clinicians are encouraged to remain informed and consider these drops as a valuable adjunct for select patients.

For ophthalmologists, the key lies in careful patient selection—targeting emmetropic, early presbyopic individuals who prioritize convenience and spectacle independence. As Shamie noted, “These patients don’t yet have cataracts, and surgery may not be appropriate. For them, drops represent an elegant and practical solution.”