s THE AGING LENS HOW PRESBYOPIA CORRECTION DROPS WILL CHANGE MY TREATMENT REGIMEN

One drop is close to market, potentially bringing a new option to many patients.

BY DAMIEN F. GOLDBERG, MD

ow often does a new patient loaded questions, I always feel the need them on the options at our disposal, walk through your door and to backpedal a bit and launch into a including reading glasses, monovision ask, “Doctor, why do I need full explanation of the aging process contact lenses, and surgical solutions. If three pairs of glasses, one for and presbyopia. the patient seems interested in surgical Hdistance, one for computer, and one Coincidentally, as I’m now in my correction, our discussion moves for reading?” or, “Doc, I can’t stand my late 40s, I find myself feeling the same to monovision LASIK, inlays, and progressive lens. Is there anything you frustrations as my patients. Like them, refractive lens exchange (RLE). can do to help me?” Then there’s my I am none too fond of the aging eye For patients in the 55-to-60-year personal favorite, “Doctor, this is it! phenomenon and the inevitable age range with incipient cataracts, Am I finally ready to have laser vision weakening of my near vision. no concomitant eye disease, and an correction and get rid of my reading Nonetheless, these conversations interest in surgical solutions, I feel glasses?” When faced with those with patients continue. I educate comfortable recommending RLE. If

70 CATARACT & REFRACTIVE SURGERY TODAY | MARCH 2020 THE AGING LENS s

provide patients with more near vision because of the larger depth of focus “I BELIEVE THAT PATIENTS WHO ARE (DOF) with smaller pupils. Just as NOT QUITE READY TO COMMIT TO with a camera when the shutter size is decreased, the DOF for near objects REFRACTIVE SURGERY WILL FIND THESE becomes extended. The trick will be balancing a smaller REVERSIBLE EYE DROPS THAT CAN pupil to improve DOF without MAINTAIN THEIR ACCOMMODATION compromising vision in mesopic and scotopic lighting conditions. VERY ATTRACTIVE, AND MY PLAN IS TO Some patients may note the loss of contrast with the smaller pupil and START WITH THESE PATIENTS WHEN a compromise in distance vision. INTRODUCING THESE AGENTS INTO MY Another potential side effect of miotics is brow ache caused by the CLINICAL PRACTICE.” contraction of the ciliary muscle. Luis Felipe Vejarano, MD, of Popayan, Colombia, internationally pioneered one of the first medications for presbyopia, FOV Tears.1,2 As he explained to me, most patients will not have these complaints because the miotic concentrations in many of these

A the patient is a high myope, I caution won’t. Rather, they’ll opt to continue about retinal detachment, and I tell to wear their readers because hyperopic patients that RLE can be the available solutions just aren’t very effective for them. Many of my compelling enough. patients have experienced satisfying Enter a pharmacologic solution outcomes with monovision IOLs, for presbyopia. We are about to low-add multifocal IOLs, extended see, for the first time, medications depth of focus (EDOF) IOLs, come to our presbyopic patients’ accommodating IOLs, and, most aid. These rapid-onset eye drops will recently, trifocal IOLs. help reestablish near sight without compromising distance vision.1-7 A DIFFERENT STORY This is a truly remarkable feat that For 40-to-55-year-old patients, I expect early-stage presbyopes to B however, it’s a different story. embrace because they will be able This patient population is active, to maintain their binocular distance and these patients still have their and near vision without sacrificing accommodation. As a conservative accommodation. What’s more, if they surgeon, I believe that RLE may be too dislike the effects of the drops, they aggressive in these cases. Alternative can discontinue their use. In a nutshell, surgical solutions may be better having presbyopia correction drops suited for these patients, but the available to my patients will change downside is that the results of those my treatment regimen, especially for procedures are finite and may last patients with early-stage presbyopia. only 5 to 10 years. Some patients will remain FIRST OUT OF THE PIPELINE motivated and pursue monovision The first presbyopia eye drops to LASIK or corneal inlays, but others become available will be miotics that Figure. EyeFocus (A) and EyeFocus+(B) packages.

MARCH 2020 | CATARACT & REFRACTIVE SURGERY TODAY 71 - n -

Ophthalmol Eye Contact Lens. . 2019;8(1):31-39. . 1999;106(12):2281- . 2017;4:3. Erratum in: Eye Vis Ophthalmol Ther Ophthalmology Eye Vis (Lond) . 2019;35(12):803-814. Editorial Advisory Board CRST J Refract Surg . 2016;5(1):63-73. Partner, Wolstan & Goldberg Eye Associates, Partner, Wolstan & Goldberg Eye Associates, [email protected] Member, Financial disclosure: Consultant (Allergan, Torrance, California Ocular Science)   february-2016. Accessed January 29, 2020. DAMIEN F. GOLDBERG, MD n n n n learns that a noninvasive solution can solution noninvasive a that learns withoutvision binocular maintain will We accommodation. affecting but,effects, side of mindful be to have presbyopic patientsoverall, many of our this innovation. stand to benefit from JL. Pharmacological treatment of 1. Renna A, Vejarano LF, De la Cruz E, Alió eye drops: a pilot study. presbyopia by novel binocularly instilled Ther new a of use the with improvement vision Near JL. Alió F, Vejarano V, Vargas 2. a prospective, consecutive inter topical compound for presbyopia correction: ventional non-comparative clinical study. detachment after clear lens extraction 3. Colin J, Robinet A, Cochener B. Retinal for high myopia: seven-year follow-up. 2284; discussion 2285. strategies for presbyopia 4. Montés-Micó R, Charman WN. Pharmacological correction. 5. Renna A, Alió JL, Vejarano LF. Pharmacological treatments of presbyopia: a review of modern perspectives. (Lond). 2017;4:9. 6. Abdelkader A. Improved presbyopic vision with miotics. 2015;41(5):323-327. 7. Donofrio Angelucci D. Presbyopia eye drop targets miosis and accommoda tion. Refractive Surgery Outlook. February 2016. http://isrs.aao.org/resources/ I expect that presbyopia drops willdrops presbyopia that expect I My impression is that presbyopia- that is impression My these agents into my clinical practice. clinical my into agents these publicgeneral the as traction gain Rowen, MD, FACS, on page 66.) page on FACS, MD, Rowen, POTENTIAL USE be will medications correcting whopatients our of many for impactful Iglasses. reading from freedom want quitenot are who patients that believe surgeryrefractive to commit to ready thatdrops eye reversible these find will accommodationtheir maintain can startto is plan my and attractive, very introducingwhen patients these with focus on softening the aging lens. There lens. aging the softening on focus presbyopia that evidence strong is causing bonds disulfide to due occurs lenseliciting and crosslinking protein EV06; (previously UNR844 stiffening. Novartis),1.5%, ester choline acid lipoic andreduce can trials, clinical in still bonds disulfide the break potentially henceelastic, more lens the make and accommodation.some restoring dropsmiotic on more For note: (Editor’s Sheri by article the see pipeline, the in Other pharmacologic presbyopiapharmacologic Other Dr. Vejarano, who collaborated withcollaborated who Vejarano, Dr. Companies developing mioticdeveloping Companies be similarly effective to FOV Tears, FOV to effective similarly be sizepupil decreased triggering improvedand miotics by caused body.ciliary the at accommodation willpipeline the down coming solutions drop is a compounded combinationcompounded a is drop twoin offered be will that solution EyeFocus+and EyeFocus strengths, (Figure). soon-to-launchthe develop to OSRX willEyeFocus that predicts drop, drops include Allergan, PresbyopiaAllergan, include drops andPharmaceuticals, Orasis Therapies, Science). Ocular of affiliate (an OSRX launchto expected is EyeFocus OSRX’s inStates United the in commercially Theyear. thisof quarter second the used for glaucoma. The reality, hereality, The glaucoma. for used a notice will patients most that is said, visionnear in improvement significant well.works it that feel and MORE TO COME presbyopia eye solutions are far lowerfar are solutions eye presbyopia pilocarpineof versionsearlier than

s THE AGING LENS