Of the 128 million Americans between the ages of 40 and 70, about 70% report wearing some sort of vision correction, and the vast majority have issues with current presbyopia-correcting options. One reason is that we can’t yet restore natural accommodation, so proper expectations must be set. There are numerous effective options, including spectacles, contact lenses, surgical procedures and, now, therapeutic agents.
Presbyopes are growing at 10 times the rate of the pre-presbyopic population. The typical patient’s frustration concerns how presbyopia interferes with everyday activities such as shopping, texting and reading a menu. Comments in surveys state that reading glasses are inconvenient, embarrassing and make wearers feel old.
Knowing their motivation, understanding this population and educating them on why they are losing their near vision (without getting into every scientific detail) will increase your success in presbyopia management.
Components of Accommodation
Recall the triad that occurs with accommodation: convergence, pupil constriction and lens flexure. This becomes the model of what you need to measure in presbyopic patients.
Binocular function is extremely important. Patients with convergence insufficiency (CI) tend to develop presbyopia earlier and may do better with certain spectacles but not others. For example, patients with digital eyestrain from prolonged device use but also exophoria with CI may not do as well with progressive lenses unless the minor eye misalignment is corrected first. Consider brushing up on binocular vision testing or purchasing a Neurolens diagnostic device.
Pupil testing is critical, as many significant conditions ranging from Horner’s syndrome to glaucoma can be determined this way. Obtaining a good baseline with a device such as the EyeKinetix (Konan Medical) will not only uncover potential issues related to the pupil using miotic agents but could also anticipate why a patient—e.g., one whose pupils don’t constrict enough—might fail with therapeutic drops.
Finally, an effective fundus exam that includes the peripheral retina should be documented before prescribing presbyopia drops. Some new technologies like confocal retinal imaging (iCare DRSplus/Eidon) may allow for more realistic color reproduction.
Surgically, the best options focus on the lens—why treat the cornea when the lens is the problem? The most recent trifocal and extended depth of focus IOLs have improved results, with less night vision disturbances. The Light Adjustable Lens (RxSight) has the ability to adjust the lens power after surgery, increasing accuracy and allowing more patients to succeed with blended vision options.
Newer presbyopic contact lens materials that maintain 95% of their water content after 16 hours of wear (Bausch + Lomb Ultra for Presbyopia) may greatly help those that experience concomitant dry eye issues.
Newly FDA-approved Vuity (Allergan) is 1.25% pilocarpine in a formulation that the manufacturer says will allow the acidic pH to quickly equilibrate once placed in the eye to minimize discomfort. In clinical studies, a statistically greater number of treated patients achieved three lines of distance-corrected near vision compared to placebo. The pivotal study showed the drug effect peaked after one hour, when 37.3% of patients in the pilocarpine group achieved three lines of reading compared to 12.1% of those on vehicle. The effects declined over time, with 16.3% in the pilocarpine group and 9.9% in the placebo group achieving this outcome at six hours. Patients improved in presbyopia coping mechanisms and reading the study questionnaire, among other tasks.
Since Vuity is a prescription drug, it could bring a large underserved population into optometric offices for a comprehensive exam, where patients will not only be offered many options for presbyopia correction but may also be diagnosed with previously undetected systemic or ocular diseases. A therapeutic eye drop will hopefully benefit many patients needing help with reading a menu or a scorecard at a sporting event. Within the next few years, as many as seven other therapeutic drugs for presbyopia may enter the market, so now is the time to get ready! ν
Dr. Karpecki is medical director for Keplr Vision and the Dry Eye Institutes of Kentucky and Indiana. He is the Chief Clinical Editor for Review of Optometry and chair of the New Technologies & Treatments conferences. A fixture in optometric clinical education, he consults for a wide array of ophthalmic clients, including ones discussed in this article. Dr. Karpecki's full list of disclosures can be found here.