Where Drops for Presbyopia Fit in My Practice

When presbyopia-correcting drops first entered the market, there was a great deal of anticipation. The idea of a pharmacologic solution that could reduce dependence on reading glasses has been discussed for decades. When the first FDA-approved option became available, many of us saw it as a potential inflection point. In reality, these drops have found a place in practice, but not in the way many initially expected.

Early Promise Meets Clinical Reality With Vuity

At a fundamental level, all currently available presbyopia-correcting drops rely on the same optical principle: the pinhole effect. By constricting the pupil to approximately 2 mm, we reduce the size of the cone of light that enters the eye, which results in an increased depth of focus. This increase in depth of focus allows patients to function better at near vision. It is a simple concept, but one that can be clinically effective when applied correctly.

The first widely adopted drop, Vuity (pilocarpine 1.25%; Allergan, an AbbVie company), demonstrated that this approach works. Patients reported to us that they could read their phones, work at a computer, and complete many daily near tasks without glasses. From a purely functional standpoint, it delivered on its promise. However, adoption did not follow the trajectory that many anticipated.

Part of the challenge was perception. Pilocarpine itself is not a new molecule, and many of us have used it for years in glaucoma management. When it was introduced as a “new” presbyopia treatment, there was a sense that it was more of a repurposing than a true innovation. That alone would not have limited adoption, but it framed how some providers may have evaluated the drug.

Still, the results spoke for themselves: while the duration of effect may not have been as long as some patients hoped, the reports of real-world efficacy nonetheless signaled progress in the field.

(The US Food and Drug Administration [FDA] relied on pivotal study data to approve the four presbyopia-correcting drops on the market. See the Table “Presbyopia-Correcting Drops: Pivotal Clinical Trial Summary” for a deeper dive.)

Limitations of Pilocarpine: Mechanism, Side Effects, and Safety

More importantly, the mechanism of pilocarpine extends beyond pupil constriction. Pilocarpine also induces contraction of the ciliary muscle, which has several downstream effects. Patients may experience brow ache or headache, particularly early in their course of use. A smaller pupil reduces the amount of light entering the eye, leading to dimmer vision, especially in low-light environments. For many patients, these effects are transient or manageable, but they are real and need to be discussed with patients before initiating treatment.

The more significant issue emerged in real-world use. While clinical trials did not demonstrate a meaningful signal for retinal complications,¹ post-market surveillance told a more complicated story. Reports of retinal tears, detachments, and other vitreoretinal events began to surface, with the US FDA Adverse Events Reporting System (FAERS) reporting 71 serious vitreoretinal complications within the first year of approval.² These were not necessarily common events, but they were enough to create concern among both providers and patients.

When we step back and think about the mechanism, this is not entirely surprising. Contraction of the ciliary muscle can shift the position of the vitreous. In a patient population that is often in the early stages of vitreous liquefaction and posterior vitreous detachment, this mechanical change may contribute to tractional events in susceptible individuals. Once I recognized this risk, I more carefully selected and educated patients.

Duration and Practical Use Challenges

Another practical limitation of pilocarpine-based drops is duration. The effect typically lasts 4 to 6 hours. For many patients, that does not align neatly with their daily schedule. Early labeling as a once-daily medication created confusion, as patients quickly realized that the effect wore off before the end of the day but were unsure if reapplication was safe. While subsequent guidance clarified that a second dose could be used, that initial mismatch between expectation and experience created friction.

Next-Generation Drops

Newer formulations have attempted to address these issues. Qlosi (pilocarpine 0.4%, Orasis Pharmaceuticals, Inc.) takes a lower-dose approach and is designed to improve comfort. The underlying hypothesis is straightforward: if we can achieve sufficient pupil constriction with less ciliary muscle involvement, we may reduce side effects and potentially mitigate risk. Indeed, this hypothesis proved true in a recent study comparing the OCT thickness of the ciliary muscle at distance and near in patients using Qlosi, pilocarpine 2%, and balanced salt solution (BSS).³ The study found pilocarpine 2% showed a statistically significant change in ciliary muscle thickness at near that was not observed in the BSS and Qlosi groups. Ciliary muscle thickness with Qlosi nearly matched the ciliary muscle thickness of BSS, showing there is a dose-dependent effect with pilocarpine 2%.

Early data and clinical experience suggest that this may be the case. A headache rate of 6.8% was reported in the phase 3 NEAR trial, compared with a 14.1% rate seen in the GEMINI 1 study.^1,4 (It should be noted that no patients in GEMINI 1 discontinued use due to headache, and the means of assessing headache in NEAR and GEMINI 1 were not identical.) The lower reported rate of headache with Qlosi may be due to the reduced contraction of ciliary muscles with a lower concentration of pilocarpine.

To date, there have not been reports of retinal detachment associated with Qlosi, although it is still early in its lifecycle. From a practical standpoint, Qlosi feels like a drop that balances efficacy with comfort.

Vizz (aceclidine 1.44%, Lenz Therapeutics, Inc.) represents a more meaningful shift. Rather than relying on pilocarpine, it uses aceclidine, a molecule that more selectively targets the iris sphincter. The goal is to achieve the same pinhole effect while minimizing or avoiding ciliary muscle contraction altogether.

In practice, this distinction matters. The theoretical risks associated with ciliary body contraction are obviated if the mechanism of action bypasses the ciliary body altogether. Another important advantage is duration. Vizz can provide a therapeutic effect for up to 10 hours, which aligns more naturally with a patient’s day. For some patients, that alone makes it a more attractive option.

Yuvezzi (carbachol and brimonidine tartrate ophthalmic solution, Tenpoint Therapeutics, Ltd.) was approved by the FDA in April 2026 based on results from the BRIO-I and BRIO-II studies.⁵ In BRIO-I, combination therapy was found to be superior over carbachol alone or brimonidine alone.⁶ In BRIO-II, Yuvezzi was shown to be superior to vehicle alone for improvement in near vision.⁶

Yuvezzi relies on carbachol to constrict the iris sphincter and ciliary body.⁵ Brimonidine tartrate, meanwhile, blocks contraction of the iris dilator muscle and relaxes tonic contraction of the ciliary muscle, which allows better selectivity for the pupil and increased bioavailability of carbachol in the aqueous humor.⁵ Per Abid et al, the addition of brimonidine reduces the side effects of inducing the pinhole effect for a sustained period.⁶ Eye pain upon instillation, eye irritation upon instillation, visual impairment, and headache were the most commonly reported side effects in BRIO-II.

Setting Expectations and Selecting the Right Patient

Even with these improvements, presbyopia-correcting drops remain a selective tool rather than a universal solution. Cost is often cited as a barrier, but in my experience, it is not the primary issue. Most patients in the target demographic are willing to pay out of pocket for a solution that improves their quality of life. The more significant barrier is expectation.

These drops do not replicate the clarity of reading glasses. When a patient puts on a pair of readers, the improvement is immediate and dramatic. With drops, the effect is gradual. Further, patients gain functional near vision, but not the same level of crisp, high-contrast detail. I find that if patients expect a “wow” moment, they are often disappointed.

For that reason, I spend a significant amount of time on expectation setting. I explain that these drops improve depth of focus. They are designed to help patients function, not to deliver perfect vision. I also encourage patients to use them multiple times in different settings before deciding whether they are effective. A single trial does not provide enough information.

I also position these drops as situational tools. Many patients do not want or need all-day pharmacologic correction. They may prefer to use drops for a dinner out, a social event, or a specific block of work. In that context, the flexibility of a shorter-acting drop can actually be an advantage. Conversely, patients who want a longer duration may prefer a once-daily option.

Patient selection remains critical. The ideal candidate is typically between 45 and 60 years old, with minimal refractive error and a strong desire for a glasses-free option. Equally important is the absence of risk factors such as significant myopia, lattice degeneration, or a history of retinal issues. In patients with those risk factors, I am more cautious and may steer them toward other options.

Ultimately, presbyopia-correcting drops have earned a place in practice, but they are not a replacement for other modalities. They are one tool among many. When we use them thoughtfully, in the right patient, with clear expectations, they can provide meaningful benefit. When we oversell them or use them indiscriminately, they fall short.