Nonsurgical Solutions for Common Causes of Aging in and Around the Eye

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What does it mean when our patients begin to confront signs of aging, and how can we help?

By Richard A. Adler, MD, FACS

Very often it is both visible and invisible evidence of aging in and around the eyes that brings patients into our offices for the first time. Many have never had any medical issues or even an eye examination. But now, they are suddenly bothered by evidence of aging: presbyopia, drooping lids, and lines around their eyes. As physicians, we try to be attuned to the person behind the eye. Now with nonsurgical solutions such as Vuity (pilocarpine HCl ophthalmic solution 1.25%; Allergan), Upneeq (oxymetazoline hydrochloride 0.1%; RVL Pharmaceuticals, Inc), and Botox (OnabotulinumtoxinA; Allergan), we have a package of options that addresses patients’ concerns by providing a rejuvenation of their youthful spirit without taking them to the operating room.

On Aging
A 2008 study by Blanchflower and Oswald1 identified a statistically significant U-shaped curve in terms of happiness throughout life for people living in 72 different countries. Their survey found that there is a happiness high point in youth and again when people are older with a low point that occurs around age 46. 

I often joke that for many, it happens the first time someone calls them sir or ma’am. Maybe they have started to develop ptosis, wrinkles around their eyes, and the need to use reading glasses. These folks have never really thought about aging, but now they are faced with the inevitable.

The term midlife crisis, coined by psychoanalyst Elliott Jaques in a 1965 paper,2 is the moment when one realizes there are fewer days left ahead than behind. It brings a sensation of amazement and despair, and for many people reading glasses are the benign intervention that brings about this malignant realization. Carl Jung said, “We cannot live the afternoon of our lives according to the program of our mornings.” In other words, 40 is the old age of youth, and 50, is the youth of old age.

Presbyopia is Ubiquitous
Presbyopia is the most common condition we ophthalmologists see, affecting approximately 128 million Americans.3 There is no other condition that is as prevalent; 100% of our patients will develop presbyopia, and it is a progressive condition. Compare that to dry eye, where about 60% of patients with the condition have no symptoms.4 Because we spend so much of our lives at arm’s length, presbyopia affects people in meaningful ways. Consider the dramatic statistics for cell phone use: most Americans check their cell phones every 10 minutes or 96 times a day.5 The average American will tap, click, and swipe their cell phone 2617 times a day, and the top 10% of users will do that 5417 times a day.6 This represents a near constant reminder of near vision loss. 

FDA-approved presbyopia-correcting drop Vuity has a role in treating presbyopia patients across the age spectrum. Its approval was based on data from 2 pivotal phase 3 clinical studies that included 750 participants with presbyopia ages 40 to 55. They self-administered one drop of the product or placebo once daily in each eye. Both studies met their primary endpoints with a statistically significant proportion of treated participants gaining 3 lines or more in mesopic, high contrast, binocular distance-corrected near visual acuity, without losing more than 1 line of corrected distance visual acuity at day 30, hour 3, versus placebo.

Emmetropic patients with mild presbyopia are an obvious starting point for this solution—they are often the ones who are most frustrated by their near vision loss as they are just discovering the difficulty and they are not interested in wearing glasses. A second category of likely candidates are those who invested significant money in LASIK and are now becoming presbyopic. They certainly do not want to wear glasses nor are they ready for refractive lens exchange or cataract surgery. Finally, cataract patients who did not get as much near vision from their surgery as they hoped are patients who can benefit from Vuity.

Ptosis: Underdiagnosed, Underappreciated
Ptosis is a common sign of aging that I believe we both underdiagnose and underappreciate. As with early presbyopia, even mild ptosis can significantly distress patients. Many times, they use the wrong words to describe why they are unhappy with their eyes, saying they are bothered by their sleepy, heavy-lidded, or bored appearance. Sometimes patients remark that they have a lazy or a small eye, and they wish for a more alert, well-rested look. Remember, even for patients with a structurally “normal” eyelid, “normal” changes of aging are precisely the problem and they are seeking an improved “normal”.

Upneeq represents the only FDA-approved pharmaceutical indicated for acquired blepharoptosis. Approval was based on two 6-week randomized, double-masked, placebo-controlled Phase 3 efficacy studies of 304 patients that found the oxymetazoline drop was associated with significant improvements compared with placebo in primary superior visual field and eyelid lift. It was well tolerated over 12 weeks when administered once daily in the morning. 

The value of thinking aesthetically can lead to what I call “the benefit of the unexpected benefit: After all, most patients are unaware of many of these treatment options. A patient who comes in not knowing there is a nonsurgical option to address a concern like ptosis and leaves with an effective treatment is not only excited but will also share that excitement with their friends. The unexpected nature of the benefit adds additional value for the patient.

Botox and Other Injectables
Botox has been around for several years. As an ophthalmologist who believes in complementary and integrated care, I have been offering it to patients since 2007. Incorporating it into practice has always made sense for eye care specialists because we are, after all, the experts who are trained in the ocular area anatomy. The eye care field lends itself naturally to introducing aesthetic and lifestyle services. In the past, many may have considered and dismissed adding the product, but now may be the time to reconsider. Along with Vuity and Upneeq, it can be thought of as part of a cohesive, nonsurgical package. Botox is effective and patients appreciate that it is not a lengthy process.

In my practice, I see a clear synergy between Botox and Upneeq. I encourage every Botox patient to leave with a prescription for the drop because although Botox lifts the brows, it does not lift the lids. It is a perfect complement, and it also makes people feel as though they have received a better injectable service. Remember, these are often the same patients who are concerned about presbyopia because they do not want to wear reading glasses that make them appear older. It is easy to see why these individuals would be interested in all 3 of the nonsurgical options discussed here. Offering them together frequently appeals to the same patient type.

How to get Started
When evaluating patients, I look for clinical connectors. It is a good indicator that patients who use Lumify (brimonidine tartrate ophthalmic solution 0.025%; Bausch + Lomb), Latisse (bimatoprost ophthalmic solution 0.03%; Allergan), wear heavy mascara, have lash extensions, opt for colored contact lenses, select premium lenses, or have had LASIK will be interested in offerings like Vuity, Upneeq, and Botox. 

Yet, patients themselves might not even bring up these types of issues around the signs of aging for 3 reasons: they don’t know an option exists, they are timid about discussing aesthetic concerns with their ophthalmologist, or they do not have the correct language to describe their issues. Starting the discussion does not have to be difficult or take a lot of time and we need to gracefully broach the topic without making them feel more self-conscious about their appearance. My favorite approach is to say, “You’ve done a great job of taking care of the inside of your eye. Do you have any concerns about the outside?” We do not want to point out things that are not troubling patients. If they start to express dissatisfaction regarding the appearance of their eyes and surrounding area, they are likely to be interested in a nonsurgical solution to their signs of aging. These discussions do not have to compete for time used to discuss diseases like glaucoma, macular degeneration, and dry eye—aesthetic-related visits can be scheduled for a different day. 

Similarly, ophthalmologists should not be concerned that these products compete with their surgical practice. They should be viewed as complementary solutions that can elevate their surgical results and set them apart from their competitors. Premium cataract surgery patients desire a premium experience, and that might mean using a drop like Upneeq, for example, or enhancing their results with Vuity. Like other areas of healthcare, ophthalmology is increasingly embracing and emphasizing wellness and prevention, moving toward nonsurgical treatments. These products help us achieve excellent results by attending to the details that encompass the entire patient—including their psychosocial well-being. Indeed, there are many good doctors out there, but there are far fewer good experiences.

Richard A. Adler, MD, FACS is in Private practice, Belcara Health, Baltimore; Assistant Professor of Ophthalmology, Wilmer Eye Institute, Baltimore
Contact: [email protected]
Financial disclosure: Speaker and consultant for Allergan, an AbbVie Company, and RVL Pharmaceuticals

1. Blanchflower DG, Oswald AJ. Is Well-Being U-Shaped Over the Life Cycle? Soc Sci Med. 2008;66: 1733-1749. http://dx.doi.org/10.2139/ssrn.1026895.
2. Jacques E. Death and the Mid-Life Crisis. Psychoanal Q. 1965; 36:502-514.
3. Zebardast N, Friedman DS, Vitale S. The prevalence and demographic associations of presenting near-vision impairment among adults living in the United States. Am J Ophthalmol. 2017;174:134-144.
4. Bron AJ, Tomlinson A, Foulks GN. Rethinking dry eye disease: a perspective on clinical implications. Ocul Surf. 2014;12(2 Suppl):S1-31.
5. Asurion-sponsored survey by Market Research Firm Solidea Solutions conducted August 18-20, 2019 of 1,998 U.S. smartphone users, compared to an Asurion-sponsored survey conducted by market research company OnePoll between Sept. 11 – 19, 2017 of 2000 U.S. adults with a smartphone.
6. Winnick M. Putting a Finger on Our Phone Obsession. Available at: https://dscout.com/people-nerds/mobile-touches.