Have a plan. Stick to the plan.
By Mark Schaeffer, OD
When I began prescribing the first FDA-approved presbyopia-correcting drop Vuity (pilocarpine HCI ophthalmic solution 1.25%; Allergan an AbbVie Company) it took a few different strategies to hone my protocol and streamline its incorporation into my practice. Our learning continues as we discover more about how the product works, and we gain more and more experience. Additional brands of presbyopia drops will become available, each being differentiated by a variety of different attributes. To be successful with this new treatment category, we must be committed to ongoing education—for ourselves and our patients—implementing a well-thought out plan of how we discuss and prescribe the product, and adapting that plan as needed. Here are some of my pearls.
(1) Educate all patients. I believe it is important to talk about the drop with all presbyopes and “pre-presbyopic” patients, even if ultimately it is not a good option for them. The last thing I want is for a patient to leave an eye exam and hear about Vuity from someone else or see a commercial and think, my doctor never told me about that—I wonder if I am a candidate?
Plus, if the current iteration of the pharmaceutical is not a good choice for them due to aspects of the product such as side effects, duration, or other usage factors, there are others in the pipeline. Like multifocal contact lenses or progressives, multiple designs provide different results even when treating the same patient.
(2) Set proper expectations. In my own experience, I want to set the bar so low for the patient that they can trip over them. I don’t discourage, downplay, or use negative language, but I think it is important to define what I consider success and make sure that aligns with the patient’s idea of success. If they want to read for 14 hours a day with no drop off, well, no pharmaceutical option is not going to meet that expectation.
The same thing is true for preparing them for side effects they may experience; we must be very straightforward. Do not use euphemisms. Instead, educate patients without being negative. Tell them what to look for, what could happen, and what to do if they encounter any of these outcomes. If they do not have any side effects, great, but if they do, they are not surprised and know they are part of the process.
(3) Get patients to commit to 2 weeks. I counsel patients to use the drop for 14 days. The more they use it, the better it works so it is key that they commit. Side effects, particularly the dimming effect, will lessen over time.
(4) A dilated exam is a must. We need to examine the fundus in all patients, making sure that there is no retinal pathology. In my practice, when they return for a follow-up in 1 to 3 months, I perform another dilated exam. In the FDA trials, there were no cases of retinal detachment. The study population had refractions of +1.00 D to -4.00 and instilled the drop for 30 days.1 In broader use, there have been cases of retinal events reported.2 Importantly, however, we do not know if the drop is causative or correlative. We have to screen these patients, and if they have an increased risk of retinal detachment due to pathology, they are not a good candidate. The only way we can know for sure is by doing the work.
Not Having a Plan is a Bad Plan
Developing a system of how presbyopia drops fit into your practice is crucial. You can’t have a process that changes with each patient. There has to be consistency in the plan of action for your staff, your patient, and yourself. It is hard to measure success if there is a different starting point for each patient. Are you going to dose the drop for some, provide samples for others, or write a prescription? Have a specific plan and protocol of how to approach every single potential Vuity patient.
I believe that, because of the way this drop works and what we now know, having patients use it for 2 weeks provides the best opportunity for success. Giving them a prescription to fill rather than a sample or dosing it in the office ensures the patient will have bought in and have a reason to continue to use it—they have some skin in the game. This also minimizes any side effects happening in your office or coordinating dilation with administering a dose and waiting for the response. Because there can be inefficiencies to dosing in the office, I prefer to dilate them and send the prescription.
Opportunities: Combine with Other Tools, Catch Diseases
Some patients may combine the drop with glasses, single vision, or multifocal contact lenses. It can be helpful for giving these patients a boost to their near vision. In one example, a patient who wears a high-add multifocal lens and likes their vision overall but wishes they had a little bit more near. I counseled them to use the drop in the morning on days when they know they will need a little bit of help. They are doing great with it.
People will still need their “traditional” solutions. In fact, Vuity has actually helped our optical. Now, patients get the luxury of choice. They get to decide whether they wear glasses or use their drops. They don’t feel like the glasses are a crutch or a symbol of aging. It becomes an “and” statement and not an “or” statement. They have options to best suit their visual needs.
Of course, let us not overlook the public health benefit of performing more dilated exams and increasing the likelihood of detecting pathology. By incorporating presbyopia-correcting drops you are helping your practice grow—patients still need visual correction like glasses and contact lenses—and you are growing a new category. You are doing right by the patient, your practice, and the profession.
Conclusion
By implementing a protocol for presbyopia-correcting drops, fully informing our patients about the option, and properly evaluating their retinal health, we will have success with these products. Optometrists should be in control of the presbyopia-correcting drop market; patients are best seen in our offices. When we do our job educating the public and our peers, we will keep patients happy and, in our chairs, and there will be no reason for them to go to anyone else.
Mark Schaeffer, OD, MyEyeDr, Birmingham, Alabama. Dr Schaeffer disclosses that he receives honoraria from Allergan and Visus.
Contact: [email protected]
Reference
- Waring 4th GO, Price Jr FW, Wirta D, et al. Safety and efficacy of AGN-190584 in individuals with presbyopia: the GEMINI 1 phase 3 randomized clinical trial. JAMA Ophthalmol. 2022;140(4):363-371. doi: 10.1001/jamaophthalmol.2022.0059.
- FDA Adverse Event Reporting System (FAERS) Public Dashboard. https://tinyurl.com/38hup75k. Accessed November 2, 2022.
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