02 December 2021
3 minutes to read
Source / Disclosures
Disclosures: McCabe claims to have been a consultant for Allergan and Visus and to have received research support from Allergan and Orasis.
As presbyopia correcting drops from different companies go through clinical trials and receive marketing approval in the United States, there is excitement as to what these drops could mean for presbyopia of age. average who do not like reading glasses.
But there are at least three key subsets of the pseudophakic patient population that could also benefit from decreases in pupil modulation.
1. Patients with complex corneas
Corneal refractive surgery patients already know the value of eyeglass independence, but many are not good candidates for high-end lenses. Biometrics in post-RK eyes, for example, can change from day to day and vision can fluctuate throughout the day, making it difficult to accurately target refractions. A small opening, implanted at the time of surgery or pharmacologically induced with presbyopia corrective drops after surgery, has the potential to both reduce reliance on glasses and improve image quality at a distance by reducing aberrations. Likewise, people with ectasia, keratoconus, irregularities due to corneal dystrophies (p.
2. Those whose objectives of independence of the show have not been achieved
We’ve all seen IOL patients with presbyopia correction who haven’t achieved the full range of uncorrected vision they hoped to have. Perhaps they had a low-addition multifocal IOL or an extended depth of field (EDOF) IOL that was not designed to provide near vision. We can now offer these patients a non-invasive way to improve their near vision after a disappointing surgical outcome. I’m not worried that a topical drop is cannibalizing our premium IOL business. Most patients who know they want to be eyeglass independent will prefer presbyopia correcting IOL to daily drops. But for those patients who are not good candidates or who do not get the desired result, the drops will allow us to refine the result.
3. Bifocal carriers
Patients who had standard monofocal IOLs and now wear bifocal lenses may benefit from presbyopia correcting drops. While they may still need distance glasses, we can increase safety and improve depth of field by getting rid of the bifocal. Our older pseudophakes are already at risk for falls, and this risk is increased when looking down through the near portion of the bifocal lenses, especially when going up or down stairs. The risk of falling is not negligible; fall-related injuries can trigger a downward spiral of hospitalization and loss of independence that is best avoided.
Implementation in ophthalmic practices
The majority of candidates for presbyopia corrective drops will likely present to primary eye care practices. However, I believe that surgical ophthalmologists will also find many opportunities to prescribe these drops.
Preoperatively, we can offer drops as an interim solution to patients in their 50s and 60s who are looking for LASIK but who would be better off waiting for lens surgery. I also think the Presbyopia Corrective Drops will be a great tool to proactively offer to patients in whom I plan to have an EDOF lens implanted as they are not good trifocal candidates. My advice to these patients, who I know are hoping to run out of glasses, is that they might need a low-add pair of readers after surgery. In the near future, I will be able to say, âWe have other tools that we can use after surgery, including eye drops which can enhance the effect. Let’s see how you heal first. The ability to modulate the pupil with a safe and well-tolerated topical drop may also increase the comfort level of surgeons with IOLs correcting presbyopia. I expect a smaller pupil will help us manage low levels of residual astigmatism, improving both distance and near vision.
Postoperatively, when the pseudophakes complain about their results and seek improvement or exchange of IOL, we will have the opportunity to educate them about the drops. Previously, we had little to offer these dissatisfied pseudophakes.
I encourage surgeons to take a close look at these new drops as they enter the market. While the active ingredients (eg, pilocarpine, carbachol, brimonidine) are familiar, future presbyopia correction drops will use lower concentrations of these agents and much more advanced formulations that may lessen side effects. that we generally associate with miotics. It will be important to review the data from the study demonstrating that the drops are well tolerated and do not degrade distance vision. Personally, I’m not too concerned about light restriction due to pupil modulation in pseudophakic patients. However, if there are any problems, the patient can simply stop the drops.
Finally, we must also pay special attention to the impact of the ocular surface. Pseudophakes are part of an age group prone to diseases of the ocular surface. It will be important to know more about the surface toxicity associated with the preservatives or the active ingredients contained in these drops. A longer lasting presbyopia drop would not only better protect the ocular surface by reducing the number of instillations per day, but would also help patients avoid the frustration of gout wear and tear.
Ultimately, I consider the presbyopia drops to be an important adjunct to the practice of lens surgery in the future.
- For more information:
- Cathleen M. McCabe, MD, can be reached at The Eye Associates, 6002 Pointe West Blvd, Bradenton, FL 34209; email: [email protected]