As eyecare professionals, we stand at the cusp of a new era in the management of presbyopia. For decades, our toolkit for addressing this universal condition has been limited to optical solutions: reading glasses, bifocals, progressive lenses, and multifocal contact lenses. Recently, the emergence of pharmacologic agents for refractive correction (PARCs) has expanded that toolkit further. This development not only expands our treatment options but also promises to shift how we approach the treatment of presbyopia and myopia, some of the most common eye conditions with life-altering implications. 

Refractive Error Correction

The refractive error correction category is rapidly growing.¹ In this context, we’re witnessing the birth of a new category that encompasses pharmacologic treatments for both myopia and presbyopia. PARCs are more than only a new treatment modality; they’re also a fundamental change in how we conceptualize and manage refractive errors.

According to current trends, the number of individuals affected by presbyopia is set to rise in the wake of an aging population.² This demographic shift, coupled with a growing desire for spectacle independence, creates a “perfect storm” of opportunity for innovative presbyopia treatments.

Potential Impact on Care Protocols

PARCs allow us to offer our presbyopic patients more choices. Rather than simply prescribing reading glasses, we can now offer a combination approach. Patients can have the option of using pharmacologic treatment for certain activities and reading glasses for others, tailoring their near-vision correction to their lifestyle needs.

Moreover, this treatment category serves as an excellent entry point into a continuum of care. As patients’ visual needs evolve over time, we can guide them through progressively more advanced solutions, from these pharmacologic treatments to multifocal contact lenses and eventually to surgical interventions when appropriate.

The Unique Role of Optometry

As PARCs become mainstay treatment options, optometrists are uniquely positioned to lead. They often engage and manage patients in their early to mid-40s who are struggling with near vision tasks, acting as a proverbial “first line of defense” against refractive conditions.³

This positioning allows optometrists to play a crucial role in educating patients about their options, including these new pharmacologic treatments. By introducing these solutions early in the presbyopia journey, optometrists can help patients maintain visual performance and quality of life as their condition progresses.

The Importance of Formulation 

When it comes to pharmacologic treatments for presbyopia, for instance, formulation matters—significantly. Just as we’ve seen with other ophthalmic medications, small changes in formulation can lead to big differences in efficacy, safety, and tolerability.

Consider, for example, the case of brimonidine. Different concentrations of this compound are used for distinct indications: from glaucoma treatment to redness relief. Alphagan P (AbbVie), containing brimonidine tartrate, is used for lowering intraocular pressure in glaucoma patients. In contrast, Lumify (Bausch + Lomb), which contains a significantly lower concentration of brimonidine tartrate, is used for ocular redness relief. These products demonstrate how adjusting the concentration of an active ingredient can dramatically alter a product’s therapeutic application for a different target audience.

However, concentration is only one piece of the puzzle. Other aspects of formulation, such as pH, vehicle, and the presence or absence of preservatives, all play crucial roles in determining a product’s overall profile.

In the context of presbyopia treatment, in which we’re dealing with an elective, quality of life-enhancing therapy, the importance of formulation is magnified. Patients seeking a break from reading glasses will have a lower tolerance for side effects or inconvenience in a cash-pay market. Therefore, the goal in developing these treatments should be to find the minimum effective concentration that balances efficacy, safety, and tolerability. Products such as Qlosi (Orasis Pharmaceuticals)—which minimizes pilocarpine concentrations and matches pH closely to natural tears—represent an attractive option.

Identifying the Ideal Patient 

As with any treatment, effective patient selection for PARCs is key. From a personal, clinical perspective, early to moderate presbyopes—those requiring reading glasses of +2.00 D or less—are likely to be ideal candidates for these treatments.

However, clinical factors are only part of the equation. The psychological profile of the patient is equally important. The ideal candidate is motivated to reduce their dependence on reading glasses. This might be due to lifestyle factors (such as hobbies or occupations for which glasses are cumbersome) or simply a desire to avoid the perceived aging effect of reading glasses.

It’s crucial that we, as eyecare professionals, have frank discussions with our patients about their goals and expectations. These treatments will make near vision clearer, but they won’t necessarily make it larger. Understanding what the patient hopes to achieve—whether it’s reading text messages, helping children with homework, or seeing a smartwatch clearly during exercise—will help ensure satisfaction with the treatment.

Looking Ahead

The emergence of PARCs marks an exciting new chapter in eye care. It offers us new tools to help patients maintain visual performance and quality of life as they age. As with any new treatment category, there will be a learning curve as we integrate new options for both presbyopia and myopia into our practices. However, the potential benefits for patients make this an endeavor well worth pursuing.

As we move forward, it’s crucial that we approach this new category with both optimism and responsibility. We must ensure patients undergo comprehensive eye exams, set realistic expectations, and understand all their treatment options. In doing so, we can better explore a new domain of presbyopia management—one capable of enhancing both visual function and quality of life for millions of patients worldwide. 

Richard L. Lindstrom, MD, is founder and attending surgeon emeritus at Minnesota Eye Consultants, senior lecturer and a trustee of the University Foundation at the University of Minnesota, and visiting professor at the UC Irvine Gavin Herbert Eye Institute. He is a board-certified ophthalmologist and internationally recognized leader in corneal, cataract, refractive, and laser surgery, as a researcher, teacher, inventor, writer, lecturer, and highly acclaimed physician and surgeon.

References

1. Refractive surgery devices market trends. Grand View Research website. Accessed October 10, 2024. https://www.grandviewresearch.com/industry-analysis/refractive-surgery-devices-market-report

2. InformedHealth.org [Internet]. Cologne, Germany: Institute for Quality and Age-related farsightedness (presbyopia): learn more – how can age-related farsightedness be corrected? In: InformedHealth.org. Institute for Quality and Efficiency in Health Care; 2023. https://www.ncbi.nlm.nih.gov/books/NBK423827/

3. Katz JA, Karpecki PM, Dorca A, et al. Presbyopia - a review of current treatment options and emerging therapies. Clin Ophthalmol. 2021;15:2167-2178.

Disclosures

Dr. Lindstrom is an equity owner in Orasis Pharmaceuticals and Visionary Ventures, and he has relationships with Alcon, Allergan, Bausch + Lomb, J&J Vision, Minnesota Eye Consultants, Unifeye Vision Partners, and Zeiss.