The first topical eye drops for presbyopia were introduced in the US in 2021 (Vuity, AbbVie). In the five years since, we have seen continued innovation, with three more presbyopia-correcting eye drops being introduced to the US market (Table 1).

It’s no surprise that the number and types of pharmaceutical options for the correction of presbyopia have continued to grow. Presbyopia affects about 2 billion people worldwide, and 128 million in the US alone (1, 2). While we have excellent surgical solutions for improving near vision at the time of cataract surgery, there haven’t been great options for presbyopes who still have healthy lenses or for pseudophakes who would like better near vision (3).  Pharmacological correction of presbyopia really fills an important gap for a very large segment of our patient population that is eager for solutions to the frustrating, age-related loss of near vision.

Understanding the options

Pilocarpine, the active ingredient in both Vuity (1.25%) and the next-to-market drop Qlosi (pilocarpine 0.4%, Orasis Pharmaceuticals), is a cholinergic agonist. It acts on the ciliary muscle and the iris sphincter to constrict the pupil. While these pilocarpine products are quite effective miotic agents, they are relatively shorter-acting drops. One of the lessons we learned early on in our experience with presbyopia-correcting eye drops was that most patients really wanted a greater durability of effect to last throughout their workday. A second dose of either of the pilocarpine eye drops can be instilled 3–6 hours after the first dose to extend their effects for a longer duration. These drops are also a good option for patients who don’t mind wearing glasses during the day at work or at home but would like to have better uncorrected near for social occasions, and therefore only need a short duration of effect.

Another lesson from early experience with the higher-concentration pilocarpine was that side effects such as brow ache, headache, irritation on instillation, conjunctival erythema, and dimming of vision, while typically mild and transient, can alarm patients and discourage use. That has led to better patient counseling so that patients are not surprised by side effects, as well as the development of newer presbyopia-correcting eye drops that aim to minimize side effects. Reducing the concentration of pilocarpine, for example, seemed to help reduce ciliary muscle spasm and its associated effects.

The next two presbyopia-correcting eye drops on the market, introduced in 2025 and 2026, rely on different active ingredients with longer durations of action, lasting up to 8–10 hours. Vizz (aceclidine 1.44%, Lenz Therapeutics) is a pupil-selective cholinergic agonist, with reportedly less ciliary muscle stimulation compared to pilocarpine (4). Although it’s a once-daily product, aceclidine patients are instructed to instill two drops a few minutes apart to achieve the maximum duration of effect.

Yuvezzi (carbachol 2.75%/brimonidine 0.1%, Tenpoint Therapeutics) is the first once-daily, dual-agent, combination eye drop treatment for presbyopia. It combines the cholinergic agonist carbachol with brimonidine, an alpha-2 adrenergic agonist that reduces the contraction of the iris dilator muscle. The addition of brimonidine has been shown to increase the bioavailability of carbachol, extending the pupil effects (5). A lower concentration of brimonidine (0.025%), commercially available as Lumify (Bausch + Lomb), is marketed for reduction of ocular redness, which may also be beneficial in inhibiting conjunctival erythema, a common side effect of presbyopia-correcting eye drops. Patients need to only instill a single drop in each eye, once daily.

Qlosi, Vizz, and Yuvezzi are all preservative-free, which is advantageous in a target population that also has high rates of ocular surface disease. Anything we can do to protect the ocular surface from preservative toxicity is beneficial for aging eyes.

Practice impact

I’ve heard some colleagues ask why ophthalmologists should care about presbyopia-correcting eye drops, given that we don’t benefit financially from writing a prescription for eye drops. I have found that these eye drops enhance patient satisfaction in the practice. They can serve as a bridge to surgical correction of presbyopia, or a bridge between LASIK and cataract surgery. If patients are less dependent on spectacles in their 40s and 50s, they will likely choose a premium lens to maintain that spectacle independence when they eventually undergo lens surgery.

I have also found pharmacological correction of presbyopia to be beneficial in my practice for limiting dissatisfaction after cataract surgery among patients with a monofocal IOL or a premium lens that didn’t quite match expectations. Despite our best efforts to educate patients, it can be difficult to convince a low myope who is accustomed to removing their glasses to read that they will no longer be able to do this after a distance-correction cataract surgery. It is not uncommon for these patients to be disappointed postoperatively, and presbyopia-correcting eye drops may provide a way to restore good near and intermediate function. I also utilize drops for patients with complex corneas who are struggling with visual quality at all distances. Small aperture inlays and IOLs have been shown to reduce dysphotopsias in patients with complex corneas (6,7), validating the benefits of pinhole optics in such eyes.

Setting expectations for functional vision

The FDA clinical trials for presbyopia-correcting eye drops all had the same primary endpoint: A ≥15-letter (3 line) improvement in binocular near vision without losing 5 or more letters (≥1 line) of distance vision. That’s a great benchmark for understanding how these drops work, but many patients benefit from improvements in near vision, even if they don’t reach 3 full lines of improvement. In the BRIO-II clinical trial of the fixed combination of carbachol and brimonidine, patients’ reading performance was also tested. Without any correction – just the eye drops – patients experienced a 39% improvement in reading speed on the validated MNREAD test developed by the University of Minnesota (8). This is a good measure of functional improvement, and one that is easy for patients to understand. They don’t really care how many lines of vision they gain; they care whether they can perform the day-to-day tasks that are meaningful to them, like seeing their phone screen or a menu without glasses and reading shelf labels at a store.

I like to set expectations that presbyopia-correcting eye drops provide functional near vision for most tasks. They do not necessarily get every patient to perfect, J1+ near vision. My patients in their early 40s often don’t need glasses for anything when using the drops. If an older presbyope wants to sit and read a novel for 3 hours, reading glasses or progressive spectacles might be a better choice for that activity. I also tell patients that near outcomes improve with consistent use. This may be due to neuroadaptation and is also likely somewhat behavior-dependent: With a little experience, patients find the sweet spot for where to hold their phone and what kind of lighting conditions they need for optimal vision.

The great thing is that, unlike with IOLs, pharmacological presbyopia correction is not permanent. Patients can start with a one-month prescription to get a full course of therapy before deciding whether to continue treatment. There is much less concern about “buyer’s remorse” that might occur if a presbyopia-correcting IOL or laser vision correction procedure doesn’t provide the vision the patient was hoping for. They can choose to use presbyopia-correcting eye drops only for workdays or weekends, or only in certain situations. It really puts the patient in control of choosing what works best for their lifestyle.

Tolerability

Side effects are generally mild, transient, and self-resolving, but each product has its own unique side effect profile, and doctors should familiarize themselves with the profiles of the presbyopia-correcting eye drops they prescribe. Brow ache and headache occur in some patients with all the drops but have been most noticeable with higher-concentration pilocarpine. Dimming of vision is most common when the drops produce a very small pupil. Ocular redness can potentially be counteracted by using a presbyopia-correcting eye drop containing brimonidine.

Somewhat counterintuitively, one way for patients to address unwanted side effects is to keep using the drops. Tolerability issues seem to diminish with prolonged use and so setting the expectation that patients shouldn’t give up on a drop after the first day is important. We recommend that all patients starting a presbyopia-correcting eye drops use it as labeled every day for a full week to understand how the drop works for them, what range of visual tasks they can accomplish, and what side effects they experience. After the first week, patients can decide if they want to continue with daily use. Educating about expected side effects also reduces the burden on practice staff. If patients know what to expect, they are less likely to call the office during initial use.

Integrating presbyopia-correcting eye drops into the practice

Pharmacological correction of presbyopia is a good choice for a broad range of patients, so I would encourage new prescribers not to overly restrict themselves to a narrow “ideal” population. At the same time, you don’t want your first patients to be far outside the expected parameters for success. Here are six categories of patients that have been most successful with presbyopia-correcting eye drops:

• Emmetropes who have never worn glasses and don’t want to start as they become presbyopic

• Hyperopes and low myopes

• Post-refractive patients. However, be careful that current refractive status doesn’t mask a history of high myopia. High axial length increases the risk of a retinal detachment and miotic eye drops should be avoided in these patients.

• Pseudophakes who are unhappy with their intermediate or near vision

• Current contact lens wearers who dislike constantly putting on and taking off reading glasses

• Monovision contact lens wearers who can wear a lower add power with the drops

All candidates for these drops should have a fully dilated exam prior to prescribing presbyopia-correcting eye drops to rule out conditions that could put the patient at risk for retinal detachment.

Given that each of these drops has a slightly different mechanism of action and duration of activity, I think it makes sense to have a go-to drop that you prescribe, as well as backup options if the first choice isn’t a good fit. We like to start with a longer-acting, once-a-day drop like Yuvezzi that balances efficacy and tolerability in a way that is more likely to be successful for most patients, but I will consider other options if the patient needs an even smaller pupil or prefers a shorter duration of action.

We have integrated these drops into the practice by simply asking patients if they're having difficulty with intermediate or near vision. If they haven’t noticed a problem or don't want any help with it, that can be the end of the conversation. But most patients in the presbyopic age range are bothered by the loss of near vision and are receptive to hearing more about their options. I give patients a sample, along with the prescription and a brochure detailing how to order the drops. Being able to start using the drops right away makes a big difference for patient to evaluate efficacy and tolerability for themselves.

Pharmacological correction of presbyopia is an exciting development from our patients’ perspective. With four topical options to choose from, this is a good time to integrate these presbyopia-correcting eye drops into your practice in a meaningful way, providing patients with additional lifestyle choices for their journey through presbyopia.