An expert panel of physicians discussed the various options that ophthalmologists should make in the treatment of presbyopia, with a focus on new myotic agents for presbyopia.
The team included S. Barry Aiden, OD, FAAO, President and Medical Director of North Suburban Vision Consultants and Eyecare Specialties, Deerfield, IL Francis Mach, MD, FAAO, FNAP, Scripps Clinic, La Jolla, Director of CA, Cornea Services and Co-Director, Refractive Surgery Andrew Morgenstern, OD, AAO, FNAP, Field Expert, Walter Reed National Medical Center, Bethesda, MD.
In general, presbyopia is more likely to affect people today due to the widespread use of digital devices in daily activities, Mach said. The patient demonstrates significant disability in daily social/work activities.
A number of treatments for presbyopia are available for OD and MD, including reading glasses, bifocals, single vision multifocal contact lenses, LASIK, PRK, clear lens extraction, phakic intraocular lenses, and miotic drops.
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Mach mentioned that the optimal treatment for presbyopia must satisfy a demanding audience and provide superior range of vision, durability, and mitigation of treatment-related side effects such as the inability of the brain to adapt to single vision and surgical complications.
Mach explained that the main theory, the Helmholtz theory, states that the lens slowly loses its elasticity with age, which becomes apparent between the ages of 40 and 50.
“Another theory is that the lens becomes stiffer and larger; the lens has some flexibility despite contraction and relaxation of the ciliary body, but the ciliary body is too large to move enough to provide little accommodation,” Mach explained.
Morgenstern explains that miosis causes pupil constriction, which results in a change in pupil size. Because of this change, the light behaves differently, meaning it no longer acts like a big wave.
“The rays are parallel, they basically have infinite focus and don’t blur,” he said.
However, side effects can occur, including ciliary spasm causing a beneficial shift in myopia, but can also cause headache or eyebrow pain. In addition, tension caused by the ciliary body can lead to posterior vitreous detachment, rupture, or retinal detachment. Mach pointed out that the goal of developing miotics is to eliminate these side effects.
In order to hit the ideal target, Morgenstern discusses the need to constrict the pupil sufficiently to achieve the highest quality of near vision, thereby optimizing the light path. Sizes under 2mm is where the magic happens.
“They have limited efficacy due to the possibility of ciliary effects and other complications,” he said.
Pilocarpine 1.25% was the first to be approved by the FDA; according to Aiden, another 1% titer pilocarpine is under development and could be approved within the next 1-2 years.
Carbachol, rimonidine, or a combination of both, powerful miotics that affect the ciliary body and cause pupillary constriction, are being investigated, Aiden said.
Another drug, aceclidine, only works on the pupillary sphincter, not the ciliary body, Mach noted, and this aceclidine appears to be a step in the right direction because it lasts longer (10 hours) than existing drugs. In addition, it is hoped that there will be significantly less vitreous tension, so there will be fewer retinal detachments from retinal breaks.
Given the variety of treatments available, the panellists suggested that a menu of options be drawn up that complemented each other. Patient and clinician education is important for optimal results.
Mach notes that when patients come to him with complaints of myopia, they have already tried glasses. He sees his survey as a golden opportunity to positively impact their quality of life, as existing treatment options, while imperfect, may address the problem of presbyopia.
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For refractive surgery, patients can choose between distance vision or monocular vision. In this case, miotics for presbyopia may be an adjunct to refractive surgery without affecting vision in one eye.
Morgenstern agrees that it is important for an ophthalmologist to educate patients about multifocal options for cataract surgery. Daily disposable contact lenses or miotic drops may be options.
“There are so many methods in optometry—great drugs, drops, glasses and contact lenses,” he said. “We can combine these things together to enable our patients to optimize their vision. In some cases, miotic drops may be helpful. Optometrists have the opportunity to discuss these options with patients.”
Morgenstern says he starts by talking to patients to determine their visual preferences based on lifestyle and needs.
“All of these innovations are amazing and mind-boggling,” he said. “As a surgeon, I have to be knowledgeable about medicines, contact lenses and glasses, even if I don’t dispense them. Ophthalmologists also need to understand all options for cataract surgery.”
Aiden concluded, “In this ever-changing environment, it is our responsibility as ophthalmologists to keep pace … and educate our patients.”
Post time: Jan-26-2023
