When should a patient with presbyopia switch from drops to a surgical treatment?

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When lens function starts to deteriorate

The decision to move to a permanent surgical treatment for presbyopia is an individual choice. It depends on the patient’s exams, their stage of life, the way their eyes are aging and their ultimate goals.

From that standpoint, it requires a discussion between the patient and the doctor about all of those things so we can try to decide on the treatment option.

Typically, when we see someone who is on presbyopia drops, we try to gauge how successful that has been for them and to what degree they find them useful as a solution to their presbyopia. For a lot of patients, they like that the drops help them read and give them a little better ability to see up close again. What they do not like is having to continually use the drops in order to achieve those results. They get to a point where they do not always want to have to carry a bottle of drops with them or deal with the issues that might come along with them, such as dimming of vision. These patients self-select for a new, more permanent treatment.

From there, it depends on the exam, the patient’s age and other issues that can come into play. What is the status of their lens? Do they have a completely clear lens, or are they developing early cataracts? What is their refractive status? Are they essentially plano, or do they have a glasses prescription in addition to using the drops?

We see this process of transitioning to surgical treatments in a range of ages starting with people in their late 50s. That is when you start to see people become more interested in a non-topical solution, and as you move up the age range, their level of interest goes up. That probably has a lot to do with deterioration of lens function, and they start to notice other changes in addition to having trouble reading. When those things start happening, it opens the door to a discussion about surgical options.

Mark A. Kontos, MD, is an OSN Presbyopia Board Member.

When a full-time solution is needed

Presbyopia-correcting drops play the role of a bridge between early presbyopes and those who need either longer duration of function of their near vision without glasses or a greater improvement in lines of vision at near than drops can provide.

As the patient’s natural lens stiffens and ages, they are no longer able to provide the amount of accommodation needed for glasses-free near vision. The three-line improvement that we can achieve with the currently available presbyopia-correcting drops is not sufficient to give them function for long enough or to a great enough degree to continue with that method of therapy.

In those cases, a patient who might have been successful with drops previously in their presbyopia journey might realize that either they need glasses to do daily tasks even when they are using drops or the effect wears off too soon. That is not what these patients are looking for. They want a more full-time solution to their near-vision problems. Currently, we do not have a pharmacologic solution for presbyopia with that kind of duration, at least not for all patients.

Those are the situations in which we say, “We do have other ways that more permanently increase your near vision throughout the entire day, and there is no waxing or waning of effect.” There is also no further or future need for increased vision. Once we have replaced the natural lens with an implant, it maintains its function for the lifetime of the patient.

Cathleen M. McCabe, MD, is an OSN Presbyopia Board Member.