EVERY DAY IN YOUR OFFICE, YOU SEE PATIENTS WHO WOULD jump at the chance to get rid of the reading glasses they need to see clearly up close. If you offered them an easy, nonsurgical treatment for their presbyopia, they would welcome the chance to scrap the spectacles.

The good news is that presbyopia-correcting eyedrops are progressing through the drug approval pipeline. The first of these medications may be available as early as next year.

In general, these drops, many based on miotics, will take effect within 30 minutes and provide near vision for 4 to 8 hours. That means your patient can instill the drops before going out to dine and needing to read a menu, for instance, or avoid constantly taking his or her readers on and off to read notes and look at the audience while making a presentation at work.

Not only could these drops be a game changer for your patients, but they also might lead to growth for your practice. They should offer a wonderful option for your presbyopic patients and provide a way to drive more patients into your office, enticing them to have regular checkups to maintain optimal ocular health.

Of course, the number of patients who might be interested is vast. The loss of clarity and accommodation that comes with presbyopia is ubiquitous. According to one estimate, 128 million US adults experience presbyopia. One market research firm estimated that the presbyopia treatment market will grow at a compound annual growth rate of 4% from 2018 to 2030.

In this article, we’ll discuss these drops, how they work, ways they can be used, and how they can serve as a gateway to provide eye care for more patients.

RANGE OF RESPONSES

You’ve probably experienced the range of how patients experience near-vision loss. Some arrive at your office highly alarmed about this loss of visual acuity; others have nonchalantly started using reading glasses and think little of it. You’ve likely explained to them the treatment options currently available, including reading glasses, multifocal contact lenses, and monovision, as well as refractive lens exchange.

Now, with the coming arrival of eye drops that can relieve presbyopia, at least temporarily, you will have a treatment option that can allow them an alternative to readers and prompt them to visit your office regularly for checkups. The drops can be used as needed.

DROPS IN DEVELOPMENT

The presbyopia drops now in development fall into two main categories: miotic and lens softening. Miotic drops change the pupil size and create a “pinhole effect.” The other type, as the name indicates, softens the lens and allows for accommodation.

A variety of miotic drops are currently in development, most of them based on pilocarpine, a drug that has been available for many years. Allergan’s AGN-190584 (pilocarpine 1.25%) ophthalmic solution appears to be furthest along. In February 2021, Allergan announced it had submitted a New Drug Application (NDA) for this formulation. The company said it expected the FDA to act on the NDA by the end of 2021.

AGN-190584, according to Allergan, is an investigational formulation of pilocarpine, which activates muscarinic receptors located at smooth muscles, such as the iris sphincter muscle and ciliary muscle. The proposed mechanism of action of AGN-190584 is through contraction of the iris sphincter muscle, constricting the pupil to enhance the depth of focus and improve near and intermediate visual acuity while maintaining some pupillary response to light. AGN-190584, says Allergan, also contracts the ciliary muscle, facilitating accommodation.

Other miotic drops in development include PRX-100 (aceclidine) from Presbyopia Therapies; Nyxol (phentolamine mesylate) from Ocuphire Pharma; VTI-001 (brimochol) from Visus Therapeutics; CSF-1 (pilocarpine) from Orasis Pharmaceuticals; and MicroLine (pilocarpine) from Eyenovia. UNR844 (lipoic acid choline ester) from Novartis is a lens softening drop in development.

The winning formulations will balance safety, efficacy, and comfort. They will be free of preservatives, so they don’t exacerbate dry eye and ocular surface disease. And they will offer the correct dose of active compound to avoid such adverse reactions as brow ache. Neither miotic nor lens-softening drops should affect distance vision.

PATIENT CANDIDATES

Perhaps the prime candidate for these drops is the patient with presbyopia, age 40 to 60, who needs to work at multiple distances, including computer work. But this is by no means the only patient who can benefit.

For instance, a younger patient may be considering LASIK but might hesitate at investing in the surgery when told they might ultimately need reading glasses as they develop presbyopia down the road. However, you might overcome that objection with the prospect of using “invisible glasses” in the form of presbyopia drops when the time comes.

Or consider a 45-year-old patient who is interested in continuing contact lens wear but is not keen on the imbalance of monovision. For this patient, you may be able to offer an option to correct both eyes for distance with contact lenses or refractive surgery and then have them use the presbyopia-correcting drop for near tasks as needed.

Similarly, for cataract patients, you may be able to offer the prospect of an alternative spectacle-free option using these drops for near vision after they undergo lens replacement with a monofocal intraocular lens (IOL). Also, these drops could play a role for patients who have multifocal contact lenses or multifocal IOLs to aid near vision.

Off label, these drops could be used to mitigate some of the dysphotopsia for patients after cataract surgery by modulating pupil function. They could also be used off label to decrease pupil size for patients who experience such postoperative disturbances as nighttime glare, starbursts, and halos, instead of today’s formulations (also off label) that have preservatives, which worsen the ocular stability of the eye surface.

SETTING EXPECTATIONS

As with any treatment, setting patient expectations will be critical. For instance, these drops are more likely to have greater effect for the early presbyope in his or her 40s compared to a 65-year-old patient who is developing cataracts.

It’s not yet known if the drops will provide any more accommodation. If both the 45-year-old and 65-year-old patient have a smaller pupil size, from an optics perspective, they should have the same vision. But from an accommodative perspective, you could assume that the 45-year-old will probably have slightly more accommodative aptitude or range than the 65-year-old.

GATEWAY TO BETTER CARE

Besides relieving presbyopia, these drops can bring to your office patients you might not otherwise see, at least not regularly. Today, you might see patients with presbyopia only when they feel their readers are changing. As marketing information becomes more widely available to the public regarding these treatment options, offering presbyopia-correcting drops in your practice could encourage patients to see you on a more routine basis for a check-up. These patients may be increasingly interested in presbyopia treatment options that don’t involve spectacle or contact lens correction.

You’re likely to see many more healthy eyes in your office, which has the potential to boost refractive surgery. And of course, these patients will have an eye exam, potentially turning up problems that may be undiagnosed, allowing you to intervene proactively.

INCREASING AWARENESS

Once the drops are available, we’re likely to see direct-to-consumer advertising, which will raise awareness. But word of mouth will be key.

To help patients literally see the benefit of these drops, you could administer them right in the office. Given that the drops are designed to work within a few minutes, the patients could experience what life would be like with this new method of vision correction.

SPREADING THE WORD

For now, your strategy should be to monitor the clinical studies and the development of these drops as they make their way through the FDA approval process. It would also be strategic to start mentioning them to your patients who present with presbyopia. You’re likely to see a very excited response.

Taking the time now to explain these drops can benefit both you and the patient once the drops arrive. These presbyopia-correcting drops have every chance of offering them a new treatment option and, at the same time, opening a gateway to better eye care for many potential patients. ■

Dr. Garg is Vice Chair of Clinical Ophthalmology, Medical Director, and Professor in Cataract, Refractive, External Disease and Corneal Surgery at the Gavin Herbert Eye Institute at the University of California, Irvine. His research includes lasers in corneal transplantation, collagen cross-linking, “big data” for cataract outcomes, and dry eye disease.

Dr. Coats works in a large OD/MD practice in Arkansas. The majority of her clinical practice is dedicated to ocular disease, comprehensive eye care, perioperative care, and contact lenses, with a special interest in the ocular surface and dry eye disease.