Click here to read the Cover Story, "Presbyopia-correcting drops broaden options for younger patients."

The future for presbyopia is bright no matter what side you are on. For drops, the benefits are that they are nonsurgical and well tolerated, and the risk profile is relatively safe. The con is that for many patients, they will not work.

Drops work well in early-stage presbyopia, but we know anecdotally that they do not work as well in older patients or those with later-stage presbyopia. There is also a possibility for some adverse effects such as headaches and eye redness, although the risk is lower than with traditional pilocarpine. That said, what is exciting is that there are many more drops in the pipeline with different mechanisms of action and agents that may have a different risk profile and may work in a broader group of presbyopes.

Refractive lens exchange with presbyopia-correcting IOLs is definitely a more permanent option that patients might prefer because there are fewer adverse events, and it eliminates the need for patients to carry drops with them. It also prevents cataracts in the future. The lenses today are not the lenses that we had 10 or even 5 years ago. The quality of vision is so much better than it used to be.

In practice, we tend to prescribe the drops to people who do not yet qualify for surgery. But if patients are looking for a more permanent option, refractive lens exchange is the way to go.

Luke Rebenitsch, MD, is an OSN Presbyopia Board Member.

Ultimately, the two options can be complementary.

Presbyopia IOLs currently can offer some people a more consistent and permanent treatment, but not everyone is a candidate for surgery.

With presbyopia drops, there is a chance to try out the vision without making a permanent decision. With an IOL, you are making a lifetime commitment. It is more difficult to reverse as an IOL exchange would be needed. There is also always the potential that patients will experience halo or glare after the procedure. This would not be an issue with presbyopia drops because if a patient was not satisfied with the vision provided by a drop, he or she could simply stop taking the eye drop.

The studies of the current presbyopia drop on the market show three lines of improvement in near vision. Depending on where patients are starting from, that may or may not be functional near vision for them. But in the right candidate, a presbyopia drop can help achieve good near vision.

Jennifer M. Loh, MD, is an OSN Technology Board Member.

Presbyopia is a dynamic condition that starts around age 40 years and can be an issue throughout life. Severity of presbyopia can range from mild presbyopia to absolute presbyopia, which is when patients cannot see anything up close.

Presbyopia drops are a wonderful tool in our armamentarium for early presbyopic patients as they can offer less dependence on reading glasses to help extend their range of vision. These drops are going to work well for 40- to 50-year-olds who still have good elasticity of their natural lens and will complement their natural lens function. Once patients get to a point at which their natural lenses can no longer help with near vision, presbyopia-correcting lenses can offer more long-lasting benefit.

In a way, presbyopia-correcting drops are a bridge therapy to surgical intervention. The holy grail is to make a lens implant that mimics the crystalline lens, a truly accommodating lens implant that can move and give you a full range of vision.

Nandini Venkateswaran, MD, is a member of the cornea and refractive surgery service at Massachusetts Eye and Ear.

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