Presbyopia is the eye condition that will impact 100% of patients at some point. It has long been said that a solution for presbyopia is the “holy grail” of eye care. While there is not yet a cure for presbyopia, there are more tools than ever before to help patients have functional near and intermediate vision while maintaining distance vision. Recently, George O. Waring IV, MD, FACS, moderated a discussion with Steven J. Dell, MD; Rex Hamilton, MD, MS, FACS; and Cathleen M. McCabe, MD, on the profound need for eye care providers to provide more presbyopia solutions to their patients and how they are doing that.
Presbyopia: Understanding the Opportunity
George O. Waring IV, MD, FACS: We know there are currently more than 1.8 billion presbyopes worldwide,1 and that a survey of patients ages 40-55 revealed that 96% of respondents are at least ‘somewhat affected’ by the symptoms, while nearly one-half find the impact of presbyopia in their daily activities to be ‘extreme.’2 This is probably the first time we are all treating a condition that we are also experiencing. How does this impact how you treat your patients?
Cathleen M. McCabe, MD: I am a presbyope and would definitely describe the impact as severe. Even as a myope, it is extremely frustrating to have difficulty at near. I can empathize with my patients in a way I never did as a younger practitioner. The sooner we talk to our patients about what is coming, sympathize, and offer treatment options, the better we serve them and the more likely we are to retain them in our practice. I have optometrists integrated in my practice, so most of our presbyopes first come to our practice to see these primary care providers. But as they move through severity of disease, working together we can offer them a continuum of treatment over time.
Steven J. Dell, MD: As the technology for treating presbyopia has improved, our practice has adapted to be more willing to intervene in earlier stages because we feel confident that we can help our patients.
Rex Hamilton, MD, MS, FACS: I have a multifocal contact in one eye, and I am unable to function without it. It is such a pain to be presbyopic! The eye care community often doesn’t consider presbyopia a true problem. The mentality is not there to look at the loss of near vision as truly disabling, and we need to change that. In our practice, we establish a continuum of care as early as possible. I use the patient education software by Rendia to show every patient how their eye is changing and how the lens will change, and then I explain to them the solutions available for the different stages of the aging eye. They know we will be with them at each stage.
Dr. McCabe: I’m always so disappointed when a previously very happy LASIK patient comes back in their 40s thinking I did something wrong, causing their LASIK to wear off. Explaining to them the process of the aging eye when they are young really prepares them for the unavoidable changes that are coming. Early in my career, I convinced a patient who was pre-presbyopic to under-correct one eye during LASIK to retain some near vision. It didn’t go well, as the patient could not immediately appreciate the tradeoff in distance vision for better near when they would become presbyopic in the future. Now, I hesitate to do that in patients who are under 40, preferring to educate them so they know presbyopia will come and that we have options when it does.
Dr. Waring: I tell patients that we typically utilize LASIK to fix focus problems we are born with, and we perform lens procedures for problems that are age-related. Once they hit presbyopia, they have taken a step off the vision cliff, and they are going to keep falling with readers, bifocals, and then cataracts. Patients understand this. We let them know it’s okay because we can help them with each of these stages. Do you see presbyopia correction becoming a pillar of your practice in the near or mid-term?
Dr. Dell: For me, it already is. Correcting presbyopia with refractive lens exchange (RLE) is a significant percentage of my weekly surgical volume. For those patients who seek to reduce or eliminate glasses with a lens procedure, my typical recommendation, whether cataract or RLE, is to offer presbyopia-correcting technology of some variety. We now have technologies that are applicable to virtually every type of patient who comes in the door, whether that’s a bit of monovision, a light adjustable lens, an extended depth-of-focus IOL, or a bifocal, trifocal, or multifocal IOL. Soon we will add a small aperture IOL to this list with the approval of the AcuFocus IC-8. There is a treatment applicable to the overwhelming majority of our patients, barring other ocular pathologies. Thus, a presbyopia-correcting option is my standard offering, and everything else is a downgrade.
Dr. McCabe: For me, it is becoming as common as astigmatism correction. There is no eye care practitioner that would ignore astigmatism when maximizing distance correction, no matter the age of the patient. We have so many options now that we can offer the vast majority of patients a range of vision. Instead of assessing whether a patient is a good candidate for presbyopia correction, we should be considering if this patient is the rare exception that cannot have a presbyopia-correcting solution. Patients are not going to have one focal point for the rest of their lives, and a lens procedure really is a lifelong choice for the patient.
Dr. Hamilton: I have reached the point that, when I fail to convince a patient of the value of a presbyopia-correcting option, it really bothers me because I’ve just relegated them to being very dependent on glasses for the rest of their life. I look for reasons to not put in a presbyopia-correcting lens, and they are few and far between.
Dr. Waring: We have reached a point where we don’t talk about astigmatism or presbyopia. We explain to patients that we are going to fix the vision problems they have while we have the opportunity, given they are an appropriate candidate. Our RLE patients are some of our most satisfied patients from Day 1. Realizing that, our lens replacement program has grown significantly, and this continues to be a group of patients with very high satisfaction. Now, we have built a practice around that.
New Solutions for Presbyopia
Dr. Waring: We are all aware that in November of 2021 the FDA approved the first prescription eyedrop for presbyopia, Vuity (pilocarpine 1.25%; AbbVie/Allergan). There has been a lot of interest and excitement around this drop. Personally, I look forward to the educational opportunities surrounding age-related blurry near vision. Have you taken any concrete operational steps to prepare for the potential influx?
Dr. Dell: While we need to gain more clinical experience with this drop, it has the potential to bring in an entire new segment of the population that has been outside our realm previously. We are embracing these patients because, although they are currently in their initial discovery phase, that will ultimately lead to surgical intervention in a large percentage of patients. We are educating our intake personnel on the new Vuity drop and then setting appointments with our optometrist to meet with them and start educating them on the aging eye and what their options are at various stages.
Dr. Hamilton: It’s great to finally have an option for those presbyopia patients who want to improve their near vision without glasses. Even though we know it is not a permanent solution, we are excited to access these patients and let them know we will be with them down the road as well. It’s a great opportunity to establish a relationship with the patient.
Dr. McCabe: Frequently we see a patient for cataract surgery, and when we talk to them about the IOL options, they say they have been using glasses for so long that they no longer mind. Vuity will allow patients to function at near without glasses and foster the desire to continue to do so once they have cataract surgery. This will help them appreciate the presbyopia-correcting IOL options we can offer them.
Dr. Dell: There is also a segment of the population that is not getting LASIK because they are worried about what will happen when they get presbyopia. Knowing there may be a pharmaceutical to help them see up close, I believe, will entice many more of them to get LASIK for their current vision concerns. This could dramatically increase our LASIK numbers.
Dr. Waring: The opportunity to use Vuity following LASIK surgery has palpably streamlined our LASIK consultation. One of the most difficult and time-consuming conversations we have is with the myopic patient in their early 40s who wants LASIK; it’s challenging trying to address their current concerns while also looking ahead to when they develop presbyopia. Vuity just brings that full circle. We are talking about blended vision less with those patients. Has it changed how you approach your myopic patients?
Dr. McCabe: I have some staff members who had multifocal contact lenses but weren’t really happy with their distance vision. They have switched to a monofocal lens for distance and are using Vuity for their near vision. My thoughts on LASIK and EDOF technology are changing, in that we have another tool to get patients the range of vision that they want and meet their expectations.
Dr. Hamilton: The fact that you can instill these drops and they work so quickly allows us to try them out in the office. Then if a patient has a positive result, we can assess the options.
Approaching Different Patient Groups
Dr. Waring: We’ve talked a bit about how our treatment of presbyopia has changed over time. We are moving toward lens-based procedures earlier, and we are considering presbyopia drops as adjunctive or standalone treatment early. Let’s talk about some specific patient groups, starting with your hyperopic and myopic patients who now have presbyopia.
Dr. Dell: How I approach patients with hyperopia changes with their degree of hyperopia. If I see a patient still in their late twenties but with a +7.0 D prescription, I tend to think about RLE much earlier because I know we can provide a dramatic improvement in function. For the fully presbyopic hyperope, it’s an easy discussion. I know I am going to treat them with RLE. We had to educate an entire generation of cataract patients that surgery with the goal of spectacle independence is not free, and that it can also improve their near vision. Now we have an entire cohort of presbyopic hyperopes who had RLE and are telling their friends how successful it was, and now we have patients that come in asking for RLE.
Dr. Hamilton: The myopic patient in the early years of presbyopia is more challenging because we worry about retinal pathology and increasing the risk of retinal tears with a lens procedure. However, vitrectomy has become so routine and low risk that we may start to think of vitrectomy as routinely paired with RLE in myopic patients.
Dr. McCabe: I certainly see that, when I am trying to get to the level of great image quality for a lifetime for my patients, the quality of the vitreous is a real factor. I think we are moving toward addressing the vitreous, and this does increase my comfort in operating on younger patients with myopia. There are a lot of patients that, if we are not willing to perform vitrectomy, they will never get the quality of vision they want or be fully satisfied.
Dr. Waring: Now I’d like to review a few cases and see how each of you would treat these patients.
Case 1: 45-year-old -4.0 D myope who is a great candidate for LASIK with an axial length of 25.5
Dr. Hamilton: I would probably start them with a distance vision contact lens plus a miotic drop, and, if that works well for them, I would go forward with LASIK for distance vision and the drop. Now that we have a miotic drop that works, I’m moving more away from monovision when performing laser vision correction or RLE, particularly with the patient who does not use monovision habitually with contact lenses.
Dr. Dell: It depends on whether they are currently using contact lenses. If they are using contact lenses all day and using readers on top of that, I would go for LASIK for distance vision, maybe with occasional use of a miotic. I do like the idea of a monovision contact lens trial in this patient, if you can get them to do it. It’s too early for me to say whether miotics will be widely accepted in these patients, but I’m certain we will learn more.
Case 2: 50-year-old plano presbyope
Dr. Dell: I think it’s important to learn who you are talking to. I love Malcolm Gladwell’s ‘Talking to Strangers’ concept, which states that we make assumptions about who is sitting across from us that may be incorrect. We need to learn what this person’s visual demands are like and what they have been doing to cope with them. If we are dealing with a detail-oriented computer programmer, then that is a whole different situation than a person who can’t imagine being seen with glasses at a cocktail party. Maybe we put a multifocal in their non-dominant eye and see how they do. Maybe we do nothing and tell them to come back when their distance vision starts to decline.
Dr. Hamilton: I couldn’t agree more with Dr. Dell. This is a wide-open frontier. If this is a true plano presbyope that still has really great distance vision, then a miotic drop is a great bridging tool because they are not yet ready for an RLE. I still have some hesitancy with the true plano presbyope with 20/20 or better uncorrected distance vision and their ability to tolerate the night vision aberrations from RLE with multifocal IOLs. The cosmetically oriented patient will usually tolerate it, but the detail-oriented patient may not. I also think there are a lot of ‘plano presbyopes’ that are actually latent hyperopes, and that is a different scenario.
Dr. McCabe: It really is essential to figure out the daily demands of this particular patient. However, we now have something very simple and completely reversible that they can try in the office. I would definitely start with a miotic drop here, and if they like it, great. If they don’t like it, we can move on to other solutions.
Dr. Dell: It is also worth pointing out that this is the type of patient that has never needed glasses before and didn’t have a clue that eventually they would lose their vision. This is a patient that really needs a continuum of care and will be a surgical candidate in 1 to 5 years.
Dr. Waring: Excellent analysis here. Treatment depends on whether there is any hyperopia, including latent hyperopia, or myopia, as well as the patient’s uncorrected reading vision. If we have a 50-year-old J3 plano presbyope, miotic drops are a great solution. If we have a 50-year-old J10 plano presbyope, then we lean more toward lens replacement.
Presbyopia Therapeutics in the Pipeline
Dr. Waring: What are some other presbyopia drops or technologies in the innovation pipeline that you are excited about?
Dr. Dell: I am consulting for Lenz Therapeutics, which has completed its phase 2 trials for a drug based on aceclidine, which also results in miosis. It’s a bit farther from coming to market, but it does have some differences to pilocarpine. Aceclidine creates a smaller pupil without ciliary spasm, and its duration of action is significantly longer than pilocarpine. It will be interesting to see how that plays out clinically.
Dr. Hamilton: I think the next new option we are going to see is the AcuFocus IC-8 IOL. This is a small aperture IOL that will not just be helpful for presbyopia in an otherwise normal eye, but may open the door for more aberrated corneas, post-refractive keratotomy patients for example, and others that are not optically ideal. The IC-8 is a really exciting and potentially expansive technology that may open up a presbyopia solution for eyes that we might otherwise be hesitant to offer a surgical solution.
Dr. Dell: That’s a great point. We’re really on the cusp of a whole revolution in small aperture optics, which will really open up options for aberrated corneas, people who have dysphotopsias with existing IOLs, and maybe even monofocal pseudophakic patients.
Dr. McCabe: I totally agree with the potential for the small aperture optics. I am also excited for technology that adjusts postoperatively, like the light adjustable lens, or the modular IOLs that allow us to choose what is best for the eye health today but then maybe change it in the future in a way that is less risky for the patient. Finally, I’m looking forward to a truly accommodative IOL. There are designs out there that look promising, and our ability to provide presbyopia correction for patients is just going to improve. In addition, I see another big focus on image quality. The IC-8 IOL allows us to really think about image quality with pinhole optics, and our previous discussion about potentially combining vitrectomies goes along with this. We are thinking more and more about the quality of the image.
Dr. Waring: That’s a great snapshot of some of the excitement and technologies being investigated. To round it out, there are also scleral procedures with laser scleral microporation, which seem to be working quite well in a minimally invasive fashion. There are a lot of exciting developments.
Looking to the Future
Dr. Waring: As comprehensive refractive surgeons, we look to help our patients through the various stages of ocular maturity through their lifetime. What kind of impact do you see these new presbyopia therapies having on our profession, particularly for refractive surgeons?
Dr. McCabe: We are in an era of redefining refractive results. In the past, the focus was on getting our patients to see their best at distance. Over the last decade, we have seen a big shift to really considering near vision. Now that we have more tools that are reliable for patients, they really can have both distance and near vision independent from glasses. The definition of a refractive surgeon now is one that provides a complete range of vision. It is a complete mind shift in how we look at what our goals are and what is an optimal result. I think we are going to see more and more focus on creating a comprehensive refractive visual solution for patients.
Dr. Dell: It will become increasingly evident to our colleagues that ignoring presbyopia, which is what we have done surgically for a long time, is not an option anymore. Correction of presbyopia is an essential component of refractive surgery, and it is the standard of care to which we hold ourselves.
Dr. Hamilton: We have a whole generation of refractive surgeons who are going to become the patients very soon, and we now have the tools to really help them. I think that is going to be a driving force in educating both our colleagues and the consumers.
Dr. Waring: Talking to this group, it is extraordinary that only around 10% of IOLs used in cataract surgery are presbyopia correcting. As we evolve and embrace the correction of presbyopia early on with drops, then with blended vision LASIK and eventually with lens replacement, I imagine we will see the emergence of presbyopia correction as a core component of refractive surgery. It will become better understood, it will be taught during fellowship training, and it will be incorporated professionally early in a surgeon’s career. The public will also begin to have the expectation that if their distance vision can be corrected, their near vision should be as well. I am excited to see this.
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.
2. Allergan Data on File.