Many years ago, when I was a first-year resident, I set two goals for myself. One was to excel and keep current in advanced cataract surgery — and with that to be an educator around the world. My other goal was to be involved in discovering the methods for presbyopia correction.

My first dreams were achieved, yet to this day we are all looking for the Holy Grail of eye care: the perfect presbyopia correction.

In our country, traditional offerings that can mitigate the condition include eyeglasses, contact lenses and surgery. Newer options have been promising, though we still have opportunities to expand on these technologies.

EYEDROPS

We now have the advent of presbyopic eyedrops increasing depth of focus (Vuity [pilocarpine HCI ophthalmic solution] 1.25%, Allergan/Abbvie), with many other formulations being tested in hopes of coming to market within the next few years. Orasis Pharmaceuticals successfully completed Phase 3 trials for a low dose pilocarpine (0.4%) in a proprietary vehicle, so we look forward to welcoming yet another treatment in the not too distant future. We also have drops in trials that can actually act on the lens itself, including Novartis’ UNR844. Our goals for these drops will include safety, efficacy and no or minimal change in distance and comfort. Several companies are vying for market share, and there appears to be room for many products, so patients will find their safe haven.

Miotic drops can be a bridge for younger presbyopes to experience spectacle-free correction and help them prepare for the coming years, and many of us are adding this to our treatments.

INTRAOCULAR LENSES

I am grateful for the IOL options available to us today as well, including diffractive and extended depth of focus lens (EDOF) technologies. These lenses now are made of very good acrylic and offer fantastic visual outcomes.

Still, we need something more. Not all patients can tolerate the few side effects inherent to splitting or diffusing light. The ideal treatment would include no change or loss in distance vision, binocularity at near to take advantage of binocular summation and the full accommodative reflex, and no diminution in contrast or light. Patients’ visual needs must be customized, as each of us have specific requirements for work and lifestyle, so we are constantly trying to find the correct treatment for each patient.

What could fit in this category? We currently have Light Adjustable Lens (RxSight), which offers customized adjustability for each patient without photopic side effects. It has been interesting to see that even the distance eye has some EDOF and that the near eye when corrected doesn’t lose that much distance. This blended vision approach has been well received in many practices even with the extended visits and time it takes to complete the process.

Accommodative lenses are being studied internationally, but we look forward to the day when we might have these in our arsenal in the U.S.

SURGERY

Minimally invasive scleral based laser procedures (ACE Vision Group) are being studied as well. With no effect on distance-corrected visual acuity, scleral approaches could be quite promising. Allograft corneal inlays (Allotex) are now coming to market in Europe. These show excellent binocular distance vision, loss of only 3-5 letters in one eye for distance with good near VA and reversibility as the lenticule does not appear to cause scarring and haze to the cornea.

CONCLUSION

I consult and advise many of the companies in this issue in hopes of achieving my dream of presbyopia correction. In the long run, we will all need in-office procedures to be able to care for the vast numbers of patients that will be knocking on our doors seeking our help.

I am truly honored to be guest editor this month and to help curate such wonderful articles from which all of us can learn. I want to personally thank all of our authors for contributing such fine educational articles. OM

Sheri Rowen MD, FACS, is medical director at Nvision Eye Centers in Newport Beach, Calif. Email her at Srowen10@gmail.com.

Disclosures: Dr. Rowen reports relationships with ACE Vision Group, Aerie, Alcon, Allergan/Abbvie, Bausch + Lomb, J&J Vision, Kala Pharmaceuticals, Novartis, OcuTerra, Orasis, Oyster Point, Tarsus, Trefoil and Zeiss.