Where Pharmacologic Presbyopia Correction Fits

Bridging the Treatment Gap

By Eric D. Donnenfeld, MD, FACS; Taylor J. Linaburg, MD; Talia N. Shoshany, MD; and Sahas Narain, MD

Refractive surgery has been defined by two distinct interventions for decades. Corneal refractive surgery is approved in the United States for patients 18 years of age or older and can provide full distance rehabilitation until they experience the onset of presbyopia in their mid-40s. Lenticular surgery, in the form of refractive lens exchange or cataract surgery, is generally reserved for patients 60 years of age or older. This results in a treatment gap for patients between 40 and 60 years of age, precisely when presbyopia becomes their dominant visual complaint.

The Burden of Presbyopia

The impact of presbyopia on patients' quality of life (QOL) is well documented.^1,2 The global burden appears similar across populations with respect to symptoms, age of onset, and the degree of QOL reduction. A QOL study identified seven themes affecting patients: activity limitation, inconvenience, health concerns, psychosocial impact, economic impact, general and ocular discomfort, and visual symptoms.³ Presbyopia has also been shown to affect emotional and social well-being, with patients reporting reduced feelings of accomplishment, decreased social interaction, and, among those experiencing substantial visual impairment, depression.³ Near vision loss can also affect occupational performance.

The Treatment Landscape

The nonsurgical management of presbyopia typically involves the use of reading glasses, contact lenses, and progressive addition lenses. A subset of patients, however, wish to reduce their dependence on spectacles for daily activities. The surgical options available to these individuals include monovision LASIK, corneal inlays, phakic IOLs, and lens-based surgery with a standard or premium IOL.

Presbyopia-correcting drops are the newest addition to this therapeutic landscape, and they offer a bridge between spectacles and intraocular or corneal surgery. These pharmacologic agents may improve patients' uncorrected near visual acuity without the risks associated with surgical intervention. Several topical candidates are moving through the US FDA approval pathway. The primary endpoint is defined as an improvement in patients' near visual acuity of 15 or more letters (3 lines) without a loss in their distance visual acuity of five or more letters (1 line). That said, a 2-line gain in near vision, or 20/40 functional near visual acuity, might represent a meaningful improvement to a patient.

Presbyopia-correcting drops induce miosis through muscarinic cholinergic receptor agonists such as pilocarpine, carbachol, and aceclidine, which selectively target the iris sphincter. The resulting pupillary constriction creates a pinhole effect that reduces the number of peripheral light rays that hit the fovea and increases depth of focus, improving near vision. Patients are often told that these drops treat presbyopia, but they actually compensate for the functional consequences of presbyopia without restoring accommodation. This distinction is not merely semantic - it defines the strengths and limitations of this form of therapy. The aging crystalline lens remains stiff, the accommodative apparatus remains dysfunctional, and the optical changes responsible for presbyopia continue to progress. What therapy changes is the individual's functional depth of focus. For carefully selected patients, that shift can provide up to 10 additional hours of useful reading vision per day.

Where Drops Fit in Practice

A Bridge Before Surgery

The greatest value of presbyopia-correcting drops may be for a population that has had few appealing options. These healthy 40- to 60-year-old professionals have started reaching for readers but are neither candidates for nor ready to commit to LASIK, refractive lens exchange, or cataract surgery. They want flexibility without permanence, and pharmacologic treatment often meets them where they are. Equally important, they remain under the care of an optometrist or ophthalmologist rather than defaulting to OTC readers, and this may prove to be one of the most durable long-term benefits of the class. Instead of losing a patient for a decade until they develop a visually significant cataract, the practice maintains an ongoing relationship with them, during which time changes in the patient's refraction, ocular surface, lens clarity, and retinal health can be monitored and the conversation about future refractive options may be continued. In this sense, presbyopia-correcting drops function as an introduction rather than an alternative to refractive surgery.

An Adjunct After Surgery

The second role for these drops is as an adjunct. Despite substantial advances in IOL technology, no current lens perfectly reproduces youthful accommodation. Patients with a monofocal, extended depth of focus, or multifocal IOL may wish to improve their near function for prolonged reading or in dim lighting conditions. Presbyopia-correcting drops can improve both distance and near acuity in select patients by extending their depth of focus. The same logic applies to patients who underwent LASIK years ago and are now presbyopic. Many of them have enjoyed decades of spectacle independence and are reluctant to wear readers. For them, pharmacologic treatment can provide an elegant solution. Rather than compete with surgery, these drops extend the performance of prior laser vision correction.

A Continuum of Care

Our patients most interested in presbyopia-correcting IOLs are those who enjoyed the benefits of corneal laser vision correction before their cataract developed. We expect something similar to occur with pharmacologic therapy - the patients who benefit from presbyopia-correcting drops are likely to be the same ones who eventually seek a premium IOL at the time of cataract surgery.

Presbyopia-correcting drops are, at their core, a bridge for patients not yet ready for surgery and an adjunct for those who have already undergone it.

1. Berdahl J, Bala C, Dhariwal M, Lemp-Hull J, Thakker D, Jawla S. Patient and economic burden of presbyopia: a systematic literature review. Clin Ophthalmol. 2020;14:3439-3450.
2. Bentley S, Findley A, Chiva-Razavi S, et al. Understanding the visual function symptoms and associated functional impacts of phakic presbyopia. J Patient Rep Outcomes. 2021;5(1):114.
3. Kandel H, Khadka J, Shrestha MK, et al. Uncorrected and corrected refractive error experiences of Nepalese adults: a qualitative study. Ophthalmic Epidemiol. 2018;25(2):147-161.

Selecting Patients and Managing Risk

By Marguerite B. McDonald, MD, FACS

Anything that expands our ability to safely help patients reduce their dependence on spectacles and contact lenses deserves consideration. Not everybody needs, wants, or is a candidate for LASIK. Not everybody is a candidate for the EVO Visian ICL (STAAR Surgical). Not everybody is a candidate for a presbyopia-correcting drop. Normalizing the expectation, however, that patients can pursue spectacle independence when they want it is worthwhile. Pharmacologic presbyopia correction is a way to move them in that direction. I do not view these drops as competitors to the surgical procedures we offer; I view them as an entry point.

A Gateway, Not a Competitor

Whenever a new therapy arrives that overlaps with an established surgical revenue stream, some physicians worry that the former will cannibalize their practice. I have watched this play out repeatedly. An example is oxymetazoline hydrochloride ophthalmic solution 0.1% (Upneeq, RVL Pharmaceuticals) for acquired blepharoptosis. Some oculoplastic surgeons hesitate to mention the prescription option because they worry it will reduce demand for blepharoplasty. I think of it differently; the drop can serve as a gateway.

When a patient tires of the monthly expense and routine of instilling a presbyopia-correcting drop, they may seek a more durable surgical option. Rather than take patients away from surgery, these therapies introduce patients to the idea of living with less dependence on optical devices. Years later, at the time of cataract surgery, they may be more receptive to surgical options for spectacle independence at distance and near based on their earlier experience.

Positioning Drops in a Refractive Practice

Patients Returning to Readers After LASIK

My practice includes many patients in their 40s and 50s who had LASIK years ago, enjoyed many years without glasses, and now require reading glasses as presbyopia progresses. My opening question to them is simple: "Were you happy with LASIK?" The answer I often hear is, "Yes, I was free of glasses for a long time, but I am back in them now. Is there anything we can do?" I tell them there might be, complete the examination, and revisit the conversation at the end. This can be an excellent opportunity to discuss the option of presbyopia drops, though it is important to get their refractive history before LASIK to be sure they were not highly myopic (> -6.00 D).

Patients Returning to Readers After Premium IOLs

A similar conversation occurs with some premium IOL patients. They may be happy they had cataract surgery but disappointed that their near visual acuity is not as strong as they expected. If they ask whether there is an option short of an IOL exchange, I introduce presbyopia drops. Once again, their refractive history before cataract surgery must be obtained.

Patients Disappointed With Their Near Visual Acuity After Standard Cataract Surgery

Presbyopia drops can also help patients who feel left behind by technological advances. I see healthy 75-year-old patients who underwent cataract surgery 10 to 15 years ago, before premium-channel IOLs were widely available. They are now wearing reading glasses while playing cards with spectacle-free friends who recently received premium IOLs. Some of the former individuals may benefit from using a presbyopia drop. Again, their refractive history before cataract surgery must be obtained.

Patients With Early Presbyopia and Those Reluctant to Wear Readers

Presbyopia drops can also be useful for patients beginning to experience a loss of accommodation who resent buying their first pair of reading glasses. When these individuals ask whether they will need to use the drop forever, I describe the modality as a bridge rather than a lifetime commitment. Additionally, the pupils slowly become smaller with age. Presbyopia drops can help them experience functional near visual acuity without readers today; later, as lenticular changes progress or their surgical candidacy changes, the conversation can shift to a longer-term refractive plan.

Lessons From the Early Rollout

A lot was learned from the first wave of presbyopia drops, and those lessons should shape how eye care providers evaluate what is coming next.

Retinal Risk and the Need for a Dilated Examination

The rollout of pilocarpine hydrochloride ophthalmic solution 1.25% (Vuity, AbbVie) underscored the importance of appropriate screening. Early reports of retinal detachment prompted a closer look at the affected patients, and I was part of a group that examined those patterns. The findings were sobering. Several prescriptions appeared to have been written for individuals without a recent ocular examination, and some patients had risk factors such as lattice degeneration or a history of laser treatment for retinal tears. In other words, these were patients for whom the use of a pharmacologic pupil-modulating agent warranted particular caution.

The lesson spread quickly. Presbyopia drops should be prescribed by an ophthalmologist or optometrist only for patients without a history of high myopia who have recently undergone a dilated retinal examination and are counseled about symptoms that urgently require an evaluation.

The Ocular Surface

Patients may be motivated to reduce their dependence on readers, but they will not tolerate hyperemia or ocular discomfort. A red eye can be a professional and social nonstarter. Tolerability should be a part of product selection and patient counseling.

Where the Category Is Going

I expect the role of presbyopia drops to continue to evolve. Since pilocarpine hydrochloride ophthalmic solution 1.25% became the first US FDA-approved presbyopia drop in 2021, three additional products have entered the category:

• Pilocarpine hydrochloride ophthalmic solution 0.4% (Qlosi, Orasis Pharmaceuticals);
• Aceclidine ophthalmic solution 1.44% (Vizz, Lenz Therapeutics); and
• Carbachol and brimonidine tartrate ophthalmic solution 2.75%/0.1% (Yuvezzi, Tenpoint Therapeutics).

Vizz is an aceclidine-based miotic with a mild effect on the ciliary body. Yuvezzi pairs a cholinergic miotic with an alpha-2 agonist designed to block iris dilator contraction.

Phentolamine ophthalmic solution 0.75% (Ryzumvi, Opus Genetics) is investigational for presbyopia and may move the category in a different direction. The agent blocks alpha-adrenergic receptors on the iris dilator muscle instead of stimulating sphincter or ciliary muscle contraction. Because the drug does not engage the ciliary muscle, it could eventually expand pharmacologic options for patients who are poor candidates for cholinergic miotics, but that use remains investigational. The US FDA has accepted a supplemental New Drug Application seeking a presbyopia indication, with a US FDA review goal date later this year.

Setting Expectations for Long-Term Spectacle Independence

Explaining to patients that freedom from glasses and contact lenses is a realistic goal for many individuals is itself a step forward. Presbyopia drops are a tool, not the whole toolbox. These agents are not a replacement for LASIK, a phakic IOL, or a premium IOL but rather a nonsurgical entry point that can change patient expectations and alter how they think about future refractive decisions.

Integrating Drops Into Refractive Practice

By Vance Thompson, MD

Benjamin Franklin famously observed that nothing is certain except death and taxes. More than 2 centuries later, I would gently revise the list. Taxes can sometimes be deferred, minimized, or avoided, whereas presbyopia is remarkably democratic. Anyone fortunate enough to live long enough will eventually need help seeing up close.

Presbyopia may be the most universal ocular complaint in refractive practice. By the time the crystalline lens is about 45 years of age, it is no longer sufficiently elastic to sustain comfortable near focus, and patients have lost the effortless visual freedom they have taken for granted for decades. The traditional surgical response has been to wait - for a cataract to ripen or the patient's level of frustration to justify a lens-based intervention. That paradigm is overdue for reconsideration.

We refractive cataract and lens surgeons have an obligation to present presbyopic patients with the full spectrum of available options. Presbyopia-correcting drops are a meaningful, US FDA-approved entry point on that spectrum. In my view, integrating this modality into a surgical practice is the right thing to do. Counterintuitively, it may also be one of the strongest strategies for growing a surgical practice over the long term. I have found that patients develop trust in surgeons who help them start the presbyopia journey with a nonsurgical option.

What the Drops Do and What They Do Not

The mechanism of currently approved presbyopia drops is straightforward. They act primarily through pupillary miosis, leveraging the pinhole principle to extend depth of focus. These agents can also mildly stimulate accommodation, which can benefit many individuals with early presbyopia.

Taken together, the clinical evidence for presbyopia-correcting drops demonstrates that these agents can provide a meaningful but time-limited improvement in appropriately selected patients' near and intermediate vision. The drops are not a permanent solution, because they do not address the underlying loss of accommodative amplitude. Time-limited relief, however, may be exactly what certain patients need. Early clinical experience with the drops also lays a foundation for a broader conversation about surgical options.

An Honest Discussion of Benefits and Risks

A patient-first philosophy requires an honest discussion of every treatment option's limitations and side effects, not only enthusiasm about the potential benefits.

Beyond the trial data, longer-term pharmacologic considerations deserve attention. Pilocarpine's cholinergic mechanism can produce a myopic shift that affects patients' distance vision, particularly in dim light, which should be discussed proactively with patients who drive at night or work in low-illumination environments. For patients with a narrow anterior chamber angle, pilocarpine presents a small but real risk of precipitating angle-closure glaucoma, making gonioscopy or anterior segment OCT an appropriate part of the preprescription evaluation. Published reports have also described a slight increase in the risk of retinal detachment,^1,2 so a dilated fundus examination is recommended before therapy is initiated.

None of these considerations should preclude us from offering presbyopia drops to appropriate candidates. Rather, the issues underscore the importance of prescribing the drops within the context of a proper ophthalmic evaluation and a realistic discussion of what the drops can and cannot accomplish.

An On-Ramp, Not an Exit Ramp

Some refractive surgeons worry that recommending presbyopia drops dilutes surgical volume or signals a lack of commitment to the premium outcomes around which their practice is built. In my clinical experience, the opposite is true.

When a patient in their late 40s hears a thoughtful, sequential presentation of options - from drops to laser monovision correction to a refractive lens exchange - rather than an immediate recommendation for surgery, I have found that trust increases. The patient feels that their best interest rather than a specific procedure is the surgeon's priority. A patient who tries presbyopia drops for 6 months and finds their visual goals met is a satisfied patient who refers friends. A patient who tries the drops, decides that their lifestyle demands something more robust, and opts to undergo a refractive lens exchange or early cataract surgery often becomes one of the most grateful surgical patients in the practice.

The conversation about presbyopia drops is best understood not as an exit ramp from surgery but as an on-ramp to a longer and more meaningful relationship with the patient. The drops are as much a diagnostic as a therapeutic tool. A patient's visual quality, compliance, and tolerance of side effects reveal a great deal about their visual system and expectations, and that information is invaluable to finding the right long-term solution for them.

A Framework for Implementation

A few principles have proved useful for integrating presbyopia drops into my practice.

Start With a Comprehensive Evaluation

I position the conversation within a comprehensive evaluation. Every candidate for presbyopia drops receives a thorough dilated fundus examination, an anterior segment assessment that includes an angle evaluation, a discussion of their refractive status, and a review of their ocular surface health. This is the standard applied before any intervention, and presbyopia drops are no exception.

Present the Full Spectrum

The full spectrum of options is presented clearly and sequentially. Modern diagnostic imaging and wavefront data can make the consultation more complete and help the patient understand why they are or are not a candidate for drops or surgery. I find that patients understand their own eyes far better when objective data are presented alongside my explanation.

Set Realistic Expectations

Presbyopia drops work best for patients in their 40s and early 50s with mild to moderate presbyopia and good distance vision, particularly those with emmetropia or low hyperopia. Patients who have a significant refractive error, advanced presbyopia, or early lens changes are likely to have a limited response to the drops and are often better served by laser- or lens-based surgery.

Schedule a Follow-up Visit

Patients are scheduled for a follow-up visit at 4 to 6 weeks. At a minimum, a member of the team should check in to see how the patient is doing and address any questions or observations. Some patients will be satisfied and remain on the drops for an extended period. Others will find themselves dissatisfied with the side effect profile, the duration of action, or their visual quality, and this becomes a natural moment to revisit their surgical options.

Conclusion

Clinical evidence supports the efficacy of presbyopia drops in appropriately selected patients. Prescribing should be anchored in a comprehensive eye examination, an honest discussion, and proper informed consent.

To thrive in the next decade, we surgeons must understand that starting the presbyopia journey with the most conservative option that meets a patient's current goals is patient-centered care. It demonstrates the integrity and breadth of expertise that build patient trust. In that sense, the presbyopia drop conversation may be among the most strategically sound moves we can make.

1. Al-Khersan H, Flynn HW Jr, Townsend JH. Retinal detachments associated with topical pilocarpine use for presbyopia. Am J Ophthalmol. 2022;242:52-55.
2. American Society of Cataract and Refractive Surgery. ASCRS Consensus Statement on VUITY (pilocarpine hydrochloride ophthalmic solution 1.25%). October 2022. Accessed July 6, 2026. https://ascrs.org/-/media/files/clinical-committee-reports/vuity-consensus-statement_october-2022.pdf