Patient Selection for Presbyopia-Correcting Drops: Think Big

Who is the best candidate? We won’t know until we try.

By Marc R. Bloomenstein, OD, FAAO

To give us an idea of who is most likely to benefit from a new pharmaceutical agent, we look to the patient population included in clinical trials. Allergan’s approval was based on data from two pivotal phase 3 clinical studies, GEMINI 1 and GEMINI 2, which evaluated the efficacy, safety, and tolerability of Vuity (pilocarpine HCI ophthalmic solution 1.25%; Allergan an AbbVie Company) for the treatment of presbyopia in a total of 750 participants aged 40 to 55 years old with presbyopia. We do not know for sure, however, the full range of potential candidates until we try the agent in the real world.

With several months of experience prescribing the presbyopia-correcting drop, I have now seen a vast swath of patients beyond those included in the studies who have had excellent results—from pseudophakes over 55 to latent hyperopes under 40. To identify appropriate candidates, I consider if this is someone who may need to employ magnification to see up close. If yes, and there are no contraindications, then I offer this drop to almost all presbyopes. Furthermore, if I have someone with a small refractive error, such as astigmatism or hyperopia, I look to Vuity to assist in their refract needs. 

Setting Expectations
As with most of our treatments, one key to success is accurately setting patients’ expectations. Any clinician knows that patients view normal side effects as “complications” if not appropriately educated and prepared. First, I let them know that the drop will burn on instillation for a few seconds due to the drug’s pH. Allergan’s pHast technology converts pilocarpine’s normal 4.5 pH to a more comfortable 6.5 or 7.0, but it still takes up to 30 seconds for the eye to adapt. Second, most patients’ eyes will become very red after putting in the drop, a transient side effect lasting only a few minutes. Third, acclimating to the miotic may cause a slight brow ache that resolves after a few days of use.

I explain to patients that narrowing their pupil size increases the depth of focus, similar to increasing the amount of light in order to see up close. I ask if they would be interested in trying a drop that accomplishes the same thing without glasses, a magnifying glass, turning on their cell phone light, or needing to be in a highly illuminated environment. Many patients who have phenomenal results with Vuity are outside the “perfect” range, and some who are well within the sweet spot do not get the benefit they expected.

Secondary Benefits
Often, we find that agents with a unique mechanism of action have a secondary mechanism of action that provides additional benefit. We see this with the glaucoma drugs bimatoprost and brimonidine which, respectively, cause rapid lash growth and whitening of the conjunctiva. For presbyopic patients struggling with glare or halos from previous refractive surgery or certain IOLs, pilocarpine can improve their quality of distance vision by reducing some of the nyctalopia.

After explaining the technology, its benefits, and what they can expect, I ask patients if they are interested in trying it. I tell them the price—$79—and that they can join Allergan’s My Vuity Points program that makes the fifth prescription free. I tell them that once I have done a comprehensive eye exam to ensure the health of their eyes, I will send in the prescription. If this is a lifestyle opportunity that I think patients can benefit from, and I do not want them to hear about it from someone else.

For the continuity of our patient’s care, we must remind them about the importance of yearly eye exams to check their ocular health. Specifically, we ensure there is no retinal pathology, inflammation, or posterior subcapsular cataract.

Case Example 1
A 55-year-old optician with previous RK was interested in learning if she was a candidate for Vuity. She told me that her vision fluctuates, and she starts to lose her near vision as the day goes on, causing her to struggle at her computer. Due to her multiple RK incisions, her small optical zone was also causing significant glare driving at night. Within an hour of her first use, she was able to see her computer clearly. After driving home that night, she sent me a text stating the drop was “amazing” and her vision was as clear as it ever had been since her RK. She continues to use the drop daily and has remarked that her life has been turned upside down for the good.

This is an example of the drop’s secondary, beneficial effect. I believe that as clinicians, part of our job is to think outside the box, to be a bit “Dr Gadget” in order to find solutions that offer multiple opportunities for our patients. As noted previously, those patients with a small amount of refractive error, whether hyperopic or myopic, pilocarpine can extend their depth of focus and improve their range of vision. Many of these patients just do not want to wear glasses.

I would encourage my colleagues not to exclude pseudosphakes as Vuity’s secondary effect increases the amplitude of accommodation allowing for improvement in what is left of their lens flexure. This is an opportunity for IOL patients who lack the near vision they desire; another tool in our tool shed.

Case Example 2
One of my technicians is an emmetropic woman in her late 40s who recently began wearing over-the-counter readers. Her distance vision is fine, but she has trouble seeing well when she is working with patients in the lane and at the slit lamp, finding herself constantly putting her glasses on and taking them off. Now, she instills Vuity when she arrives at the office and within 15 to 20 minutes, she can see well for the whole day without reaching for her readers. She is my number one advocate for the drop and feels she is more efficient at work because she can seamlessly transition between distances and lighting conditions. 

Conclusion
There’s no escaping presbyopia. When their time comes, our patients should know we understand what they are going through and that we are ahead of the curve in terms of their options. Vuity could be as commonplace as glasses, contacts, or refractive surgery in our practices. Optometry has never been myopic about new technologies, now should not be the time.

Marc R. Bloomenstein, OD, FAAO is an Optometrist, Schwartz Laser Eye Center, Scottsdale, Arizona
Contact: [email protected]
Financial disclosure: Dr. Bloomenstein is a consultant to AbbVie