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Patients can try different drops and dosing schedules to improve outcomes.
Special to Ophthalmology Times®
Worldwide, there are 1.8 billion presbyopes, many of whom have inadequate vision correction.1
The large US millennial population, estimated to be 72 million individuals, begins turning 40 this year, adding millions more presbyopes to the mix over the next 15 years.2
It is important that we recognize the impact presbyopia has on patients’ lives.
As ophthalmologists, we know this ubiquitous condition doesn’t threaten ocular health, so it is easy to be dismissive.
Our patients find it tremendously frustrating. In a recent market research study in which 1000 presbyopic adults ages 40 to 80 were surveyed, 60% ranked the loss of near vision as one of the age-related ailments that has the greatest impact on quality of life—ahead of hearing loss, arthritis, dry eye, and other conditions.3
For emmetropes, presbyopia can be particularly incapacitating, because they have never experienced vision problems.
Suddenly, their ability to use a computer, read price tags, present on a Zoom call, and even enjoy dining out is negatively affected.
The most common solution, OTC reading glasses, always seems to be in another room or left in the car when needed. My presbyopic patients tell me that reading glasses feel like a scarlet letter, announcing their age to the world.
Even under ideal circumstances, progressive glasses with the reading segment at the bottom of the prescription lens force patients to bob their heads or tuck their chins to bring the object they are viewing into the clear zone.
Wearing readers (or bifocals or progressives, for that matter) also increases the risk of falls.4
This is particularly the case in later presbyopia, when the higher add power can blur steps or curbs on a downward gaze. Additionally, spectacle multifocality impairs edge-contrast sensitivity and depth perception.4
It is very good news that eye drops intended to treat presbyopia are being developed and expected to begin entering the US market as early as this year (Table).
As we consider how these drops might affect patients and practices in the future, this is a good time to evaluate what patients need and expect from a topical solution to presbyopia.
In the market research survey, there were high levels of interest in presbyopia-correcting drops across all age groups, genders, and income levels.
I see this in my own patients. When I mention that drops might be an option for them in the future, their eyes light up immediately.
When asked about the most important features of a presbyopia drop, 96% of the survey respondents cited long duration. Essentially, they wanted it to last as long as possible throughout the day.
We know patients do not like instilling drops midday for dry eye or glaucoma, and this will likely be no different. Patients do not want to have to have to plan to bring drops with them and then stop what they are doing to instill them.
When asked more specifically about how long they want the drops to work, 73% of survey respondents said they prefer a duration of at least 7 hours (Figure).
Also of great importance to the survey respondents was that the drops work as well as their glasses or contacts, with 94% ranking this highly.
A large majority of respondents (83%) also felt it is important for adverse effects to be mild or infrequent.
As someone passionate about ocular surface care, I believe a major consideration in prescribing will be the presence of preservatives in these presbyopia-correcting drops that can negatively impact the ocular surface.
There is significant overlap between presbyopia and dry eye, because both increase in prevalence with age.
Preservatives like benzalkonium chloride (BAK) interfere with the health of the epithelial microvilli, disrupting tear film homeostasis and exacerbating preexisting ocular surface issues.
Given that we know patients want presbyopia drops to last all day, I believe a longer-duration drop will have a better safety profile because patients would use it just once a day, rather than increasing their BAK or other preservative exposure with multiple doses per day. Preservative-free options will be ideal.
Emmetropes will be the first group of people to whom I will offer presbyopia-correcting drops because they have never worn glasses and do not perceive glasses as part of their persona.
About half of people in the key demographic segment for presbyopia-correcting drops (ages 40 to 59) are emmetropes.5
I would include post-LASIK emmetropes in this initial group. They have already made a significant investment in their eyes specifically to avoid wearing spectacles.
The second group I would offer drops to would be low to moderate hyperopes.
These patients are already wearing glasses and sometimes struggle with overmagnification from a near add, so reducing their dependency on glasses will be a big benefit.
By contrast, low myopes in the –1.50 to –3.00 range likely will be the least interested in presbyopia-correcting drops because they can just remove their glasses for near vision.
The third major group I see benefitting from presbyopia-correcting drops are pseudophakes who had surgery before all the advanced multifocal and EDOF IOLs became available or who opted for monofocal IOLs and still need reading glasses.
Pseudophakes were more likely than phakic patients in the survey to express interest in presbyopia-correcting drops, with 79% of pseudophakes and 91% of premium IOL patients saying they would definitely try the drops if their doctor recommended them, compared with 58% of the entire survey population.
We also have many pseudophakes who have blended monovision, with one eye targeted for distance and one for intermediate—and neither eye seeing well at near.
It is hard to say at this stage whether monovision patients will benefit from bilateral or unilateral use of the drops, especially because not all drops that enter the market will have been tested in this subgroup.
There will be much for patients and doctors to learn as presbyopia drops become available and we all gain real-world experience with them.
I believe we will eventually be able to match drop characteristics to our patients’ needs, just as we currently select presbyopia-correcting IOLs based on patients’ ocular health, vision, and lifestyle.
The big difference, of course, is that a drop is not a once-in-a-lifetime choice.
Patients can try different drops and dosing schedules to find the one that provides the best results with the fewest adverse effects for them.
About the author
Cynthia Matossian, MD, FACS
Matossian is founder and medical director of Matossian Eye Associates, an integrated ophthalmology and optometry group practice with 3 offices in Pennsylvania and New Jersey. Matossian Eye is an affiliate of Prism Vision Group. She also serves as a clinical instructor in the Department of Ophthalmology at Temple University School of Medicine. She is a consultant to Allergan and Visus Therapeutics.
1. Fricke TR, Tahhan N, Resnikoff S, et al. Global prevalence of presbyopia and vision impairment from uncorrected presbyopia: systematic review, meta-analysis, and modelling. Ophthalmology. 2018;125(10):1492-1499. doi:10.1016/j.ophtha.2018.04.013
2. National population by characteristics: 2010-2019. United States Census Bureau. Updated June 17, 2020. Accessed January 15, 2021. www.census.gov/data/datasets/time-series/demo/popest/2010s-national-detail.html
3. Donnenfeld ED. Clinical considerations for topical presbyopia drop therapies. Burke Healthcare Research. Presented at: 2020 International Society of Presbyopia (ISOP) conference. November 11, 2020.
4. Lord SR, Dayhew J, Howland A. Multifocal glasses impair edge-contrast sensitivity and depth perception and increase the risk of falls in older people. J Am Geriatr Soc. 2002;50(11):1760-1766. doi:10.1046/j.1532-5415.2002.50502.x
5. Vitale S, Ellwein L, Cotch MF, Ferris FL 3rd, Sperduto R. Prevalence of refractive error in the United States, 1999-2004. Arch Ophthalmol. 2008;126(8):1111-1119. doi:10.1001/archopht.126.8.1111