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Digital Supplement | Sponsored by Orasis Pharmaceuticals

Presbyopia Correction Through the Eyes of a Surgeon

With limited surgical options, patients will appreciate the safety and convenience of an eye drop.

The decade between age 40 and age 50 is a dynamic time for near vision loss from presbyopia. People who never wore eyeglasses find they need readers, often before their friends need them, and myopes who wear eyeglasses or contact lenses suddenly discover they see better up close without correction. While it’s a confusing time visually for patients, it’s particularly troubling for people who are close to emmetropia, as they worry that something is significantly wrong with their vision. I reassure them and then discuss their options.

Limited Surgical Options

When emerging and early presbyopes come in to see me as a surgeon for an evaluation, I can offer two options, although neither is ideal. I may suggest monovision LASIK to give them as much freedom as possible. This takes some time preoperatively, however, as we do a monovision contact lens trial for those who are naïve to it. I also must stress to patients that this surgery will help them see at certain distances, but we cannot provide both near and distance vision in each eye of patients who are presbyopic, and their near vision will continue to degrade as they get older.

Refractive lens exchange (RLE) can be a viable option for some patients, mainly hyperopes, and I may consider it for emmetropes, depending on the patient’s age and motivation. I generally don’t offer RLE for high myopes, and even presbyopic patients with moderate myopia (–5.00 D or less) are not good candidates for RLE, because of their inherently higher risk of a retinal tear or detachment as myopes, and what they see and appreciate up close without correction may subjectively far outweigh the quality of vision they would have with our current presbyopia-correcting lenses.

As surgery candidates, presbyopic patients have limited options, particularly those who are younger and need only an extra diopter of near vision. They still have some accommodative amplitude. They just need a little extra “oomph.”

Not Just for Phakic Patients

Now in phase 3 clinical trials, a pharmacologic solution developed by Orasis (OR-uh-sis) Pharmaceuticals to treat presbyopia is designed to provide that extra “oomph” as patients traverse that decade of presbyopia onset and beyond.

A presbyopia-correcting eye drop will open up more options for our phakic patients, allowing for a greater range of vision and greater independence from spectacles. A drop that can be instilled up to four times a day will enable patients to use it when they need it most.

I’m also excited to have the opportunity to prescribe this drop for my pseudophakic patients, particularly those who are somewhat myopic in the nondominant eye. By using this drop in the nondominant eye, these patients will have more freedom and avoid the frustration of searching for their reading glasses and repeatedly putting them on and taking them off.

What We Need From A Drop

It’s so important for us to optimize vision and patient satisfaction from a symptomatic standpoint and from a visual stability standpoint, particularly when prescribing a topical therapy. Presbyopia-correcting drops should be ocular surface friendly with a low side effect profile. We don’t want to induce accommodative stress, headache, browache, or any of the issues associated with miotics. The ideal solution will have the lowest strength of active ingredient to provide the desired effect and, preferably, will be preservative-free.

New Strategy for Cataract Surgery Planning

Just as interesting as the utility of these presbyopia-correcting drops for a wide range of patients is the idea that we can plan ahead for our current cataract patients. Not all patients are candidates for, or thrilled about the side effect profile of, diffractive multifocal IOLs. I’m most excited about prescribing these drops for patients who have mini- or modified monovision and/or extended depth of field or monofocal “plus” lenses. We recognize that the small aperture IOL (AcuFocus IC-8), diffractive and non-diffractive IOL options (Tecnis Symfony, Johnson & Johnson Vision; Acrysof Vivity, Alcon), and a boosted monofocal IOL such as the EyHance lens (Johnson & Johnson Vision) will provide an extended range of vision but will generally not exceed more than 1.00 D to 1.50 D of pseudo-accommodative amplitude. Now, we can tell patients that in the future, they can use this presbyopia-correcting drop if they feel they need a boost for reading more microprint size, such as a book, a newspaper, or a journal.

When planning a monovision procedure, we want to keep visual acuity for the two eyes as close together as possible but give as much freedom from spectacles as possible. Again, we could plan modified monovision with the near eye no more than 1.50 D to give good vision at the intermediate or computer distance and then prescribe presbyopia-correcting drops for patients to use for reading or close work.

As patients get older, traditional monovision becomes more difficult. Either the near eye doesn’t have enough myopic error to support microprint (–1.50 D to –1.75 D) or the near eye may be too strong (–2.00 D or more) for intermediate vision, requiring patients to wear over-the-counter reading glasses or lean in to look at a computer screen. They’re losing stereopsis and missing curbs and encountering other difficulties with night-time driving. A presbyopia-correcting drop gives us a strategic option as we’re planning their surgery to target a weaker, more manageable myopia goal and potentially supplement with further pharmacologic correction. This will be particularly helpful for patients who don’t qualify for multifocal lenses or are turned off by the potential for positive dysphotopsias that are associated with our presbyopia-correcting diffractive technologies.

Embrace This Advanced Solution

As surgeons, we want to embrace all of the technologies available to us, and I believe a presbyopia-correcting eye drop fits this category. Not everyone will choose surgery, particularly when their options involve some level of compromise. I believe the Orasis drop will be a worthwhile alternative to spectacles for many of our patients.

What’s more, by prescribing an advanced pharmacologic solution for presbyopia, not only are we giving patients the means to maintain their independence from spectacles, we’re also demonstrating that we’re on the cutting edge of all technology, whether it’s surgical or not surgical. Knowing this, patients will be encouraged to move toward the advanced surgical options as they become more presbyopic.

author
Elizabeth Yeu, MD