Presbyopia - A Review of Current Treatment Options and Emerging Therapies

BCLA CLEAR Presbyopia: Epidemiology and impact

The global all-ages prevalence of epidemiologically-measured 'functional' presbyopia was estimated at 24.9% in 2015, affecting 1.8 billion people. This prevalence was projected to stabilise at 24.1% in 2030 due to increasing myopia, but to affect more people (2.1 billion) due to population dynamics. Factors affecting the prevalence of presbyopia include age, geographic location, urban versus rural location, sex, and, to a lesser extent, socioeconomic status, literacy and education, health literacy and inequality. Risk factors for early onset of presbyopia included environmental factors, nutrition, near demands, refractive error, accommodative dysfunction, medications, certain health conditions and sleep. Presbyopia was found to impact on quality-of-life, in particular quality of vision, labour force participation, work productivity and financial burden, mental health, social wellbeing and physical health. Current understanding makes it clear that presbyopia is a very common age-related condition that has significant impacts on both patient-reported outcome measures and economics. However, there are complexities in defining presbyopia for epidemiological and impact studies. Standardisation of definitions will assist future synthesis, pattern analysis and sense-making between studies.

BCLA CLEAR Presbyopia: Management with contact lenses and spectacles

This paper seeks to outline the history, market situation, clinical management and product performance related to the correction of presbyopia with both contact lenses and spectacles. The history of the development of various optical forms of presbyopic correction are reviewed, and an overview is presented of the current market status of contact lenses and spectacles. Clinical considerations in the fitting and aftercare of presbyopic contact lens and spectacle lens wearers are presented, with general recommendations for best practice. Current options for contact lens correction of presbyopia include soft simultaneous, rigid translating and rigid simultaneous designs, in addition to monovision. Spectacle options include single vision lenses, bifocal lenses and a range of progressive addition lenses. The comparative performance of both contact lens and spectacle lens options is presented. With a significant proportion of the global population now being presbyopic, this overview is particularly timely and is designed to act as a guide for researchers, industry and eyecare practitioners alike.

Pharmacological treatments for the correction of presbyopia

Presbyopia affects between 1.7 and 2 billion people worldwide. Presbyopia significantly impacts productivity and quality of life in both developed and developing countries. During accommodation, the human eye changes its dioptric power by altering the shape of the lens, but the exact nature of this change has not been fully explained. Recently, topical treatments have been marketed for the treatment of presbyopia and others are under investigation. In order to prepare a review of these novel therapies, we searched the major biomedical search engines. We found 15 randomized clinical trials and 12 reviews that met our review criteria. There are two different strategies for this purpose, the pinhole effect that increases depth of focus and "crystalline lens relaxation" for which parasympathetic mimetics and lens oxidation intermediates have been used. The results are generally favorable in terms of improvement of near visual acuity, although the follow-up period of the studies is short. These are novel strategies in the early stages of research that could be useful in the treatment of presbyopia.

BCLA CLEAR Presbyopia: Evaluation and diagnosis

It is important to be able to measure the range of clear focus in clinical practice to advise on presbyopia correction techniques and to optimise the correction power. Both subjective and objective techniques are necessary: subjective techniques (such as patient reported outcome questionnaires and defocus curves) assess the impact of presbyopia on a patient and how the combination of residual objective accommodation and their natural DoF work for them; objective techniques (such as autorefraction, corneal topography and lens imaging) allow the clinician to understand how well a technique is working optically and whether it is the right choice or how adjustments can be made to optimise performance. Techniques to assess visual performance and adverse effects must be carefully conducted to gain a reliable end-point, considering the target size, contrast and illumination. Objective techniques are generally more reliable, can help to explain unexpected subjective results and imaging can be a powerful communication tool with patients. A clear diagnosis, excluding factors such as binocular vision issues or digital eye strain that can also cause similar symptoms, is critical for the patient to understand and adapt to presbyopia. Some corrective options are more permanent, such as implanted inlays / intraocular lenses or laser refractive surgery, so the optics can be trialled with contact lenses in advance (including differences between the eyes) to better communicate with the patient how the optics will work for them so they can make an informed choice.

Perception and awareness of the public about presbyopia and its corrective approaches in Saudi Arabia: a population-based survey

BACKGROUND

This study investigated patients' awareness of presbyopia and its management approaches and their preferred methods for near vision correction.

METHODS

In Saudi Arabia, 785 participants (aged between 35 and 60 years) completed a structured survey online, consisting of hard copies and direct interviews. The survey consisted of twenty-eight items divided into three parts. It was designed to record participants' awareness of and preferences for presbyopia and its refractive corrections. Nonparametric tests and descriptive analyses were conducted to analyse participants' responses.

RESULT

Approximately half of the participants had difficulty with near vision activities, such as reading newspapers or using mobile phones. Among all the participants, 76% were not aware of presbyopia. The prevalence of uncorrected presbyopia was 48% of the 785. The majority (82%) felt that spectacles were acceptable for correction of presbyopia. Most reported that they did not experience social stigma when using reading spectacles (87% of participants). When asked if they were aware of management approaches other than spectacles, 72% responded with not at all. Most participants had no earlier knowledge of the use of multifocal contact lenses or eye drops for presbyopia correction (67% and 82%, respectively). In the present study, some tendencies to use corrective approaches to presbyopia other than spectacles were noted. Finally, participants' age, sex, region, education, and income had a statistically significant impact on essential parts of their responses (p < 0.05).

CONCLUSION

Presbyopia is a highly prevalent age-related ocular disorder, and a significant percentage of cases are uncorrected due to a lack of awareness or reluctance to wear spectacles. More efficient health education about presbyopia and its corrective alternatives is urgently needed.

Understanding Perspectives on Presbyopia and Use of Pilocarpine HCl 1.25% Twice Daily from Participants of the Phase 3 VIRGO Study

INTRODUCTION

The phase 3, randomized, vehicle-controlled, 14-day VIRGO study evaluated the efficacy and safety of twice-daily dosing of pilocarpine hydrochloride ophthalmic solution 1.25% (Pilo) in presbyopia. On VIRGO exit, a companion study was conducted to assess the patient experience with presbyopia and satisfaction with Pilo.

METHODS

Recruited individuals completed the Presbyopia Patient Satisfaction Questionnaire (PPSQ) plus a three-part exit survey, or a live interview. The PPSQ evaluated respondents' experience with Pilo. Survey parts 1 and 2 evaluated experience managing presbyopia before and during VIRGO, respectively; part 3 assessed future possibilities of using Pilo in real-world situations. The interview further informed the interviewees' experience with presbyopia and Pilo. The primary endpoint was responders (%) in each rating category of the PPSQ items 1-7; the secondary endpoints were summary of categorical (survey) and qualitative (interviews) responses.

RESULTS

The PPSQ and survey included 62 participants who received Pilo (N = 28) or vehicle (N = 34) in VIRGO; the interview included ten participants (Pilo, N = 4; vehicle, N = 6). Per the PPSQ, 64.3% of Pilo users reported vision improvement, including 17.9% with complete improvement; ≥ 46.4% were satisfied/very satisfied with their ability to perform daily activities, see up close unaided, and read in dim light. Among vehicle users, these percentages were 35.3%, 0%, and ≤ 23.5%, respectively. In both subgroups, ≥ 67.9% were interested in using Pilo or Pilo and eyeglasses/contact lenses in the future. Per the interview, vehicle users (n = 6/6) found the eyedrop easy to use but none experienced meaningful near-vision improvements, stopped using other correction method(s) part of the day, were satisfied with the eyedrop, preferred it over their previous correction method(s), or would continue using it if prescribed. Conversely, 75% (n = 3/4) of Pilo users responded positively to each of these six criteria.

CONCLUSIONS

Findings validate the VIRGO results and improve our understanding of the patient experience, demonstrating improved vision and satisfaction with Pilo (vs. vehicle) when performing daily activities.

Efficacy of a new refractive multifocal contact lens for presbyopia

This prospective single-arm study aimed to evaluate the clinical efficacy and safety of a refractive multifocal contact lens for the correction of presbyopia in 22 patients. The participants underwent clinical examinations before and 1 week after wearing a refractive multifocal contact lens (OptaCon ZOOM). The primary endpoints were the corrected distance visual acuity (CDVA) and distance-corrected near visual acuity (DCNVA). Defocus curve, contrast sensitivity, and ocular surface disease index (OSDI) were analyzed. A slit-lamp examination was performed for safety analysis. Contact lens comfort and patient satisfaction were assessed using a questionnaire. No significant difference in CDVA was observed before and 1 week after refractive multifocal contact lens use (p = 0.127), whereas DCNVA was significantly improved after 1 week (p < 0.001). The contrast sensitivity was not significantly affected at any spatial frequency under mesopic or photopic conditions. OSDI was significantly increased (p = 0.023). The patient-reported satisfaction scores were 96.2, 91.9, and 85.0 out of 100 at far, intermediate, and near distances, respectively. No significant adverse events were observed. Refractive multifocal contact lenses improved near vision while maintaining distance vision in presbyopic patients, without compromising contrast sensitivity. The study results suggest that OptaCon ZOOM can be considered safe and effective for the correction of presbyopia.

Evaluation of objective and subjective binocular ocular refraction with looking in type

BACKGROUND

This study aimed to compare the results of the Chronos binocular/monocular refraction system, that measures objective and subjective ocular refraction in one unit, to objective findings obtained from a conventional autorefractometer and a conventional subjective ocular refraction using a trial-frame in real space.

METHODS

Twenty-eight healthy volunteers (21.2 ± 1.5 years old) were included in this study. Objective ocular refraction was measured using two tests: the Chronos binocular/monocular refraction system under binocular conditions and a conventional autorefractometer under monocular conditions. Subjective ocular refraction was measured using three tests: Chronos binocular/monocular refraction system under binocular, monocular conditions, and trial-frame in the real space under monocular conditions. The measurement distance was set to 5.0 m for each test. All ocular refractions were converted into spherical equivalents (SEs).

RESULTS

The objective SE was significantly more negative with Chronos binocular/monocular refraction system under binocular condition (- 4.08 ± 2.76 D) than with the conventional autorefractometer under monocular condition (- 3.85 ± 2.66 D) (P = 0.002). Although, the subjective SE was significantly more negative with Chronos binocular/monocular refraction system under binocular condition (- 3.55 ± 2.67 D) than with the trial-frame in the real space under monocular condition (- 3.33 ± 2.75 D) (P = 0.002), Chronos binocular/monocular refraction system under monocular condition (- 3.17 ± 2.57 D) was not significantly different from that in trial-frame in real space under monocular condition (P = 0.33).

CONCLUSION

These findings suggest that the Chronos binocular/monocular refraction system, which can complete both objective and subjective ocular refraction tests in a single unit, is suitable for screening ocular refraction, although it produces slightly more myopic results. Furthermore, subjective ocular refraction testing accuracy in Chronos binocular/monocular refraction system can be equivalent to trial-frame in real-space testing by switching from binocular to monocular condition.

Symptomatic Presbyopia may Develop Earlier in Patients With Glaucoma-A Cross-Sectional Retrospective Cohort Study

Purpose

The purpose of this study was to explore risk factors for symptomatic presbyopia, defined as near add power ≥1.50 diopters, in patients with glaucoma.

Methods

Treated glaucoma (n = 56), untreated glaucoma (n = 21), and control individuals (n = 376), aged 40 to 55 years at first visit, were enrolled in the study, and near add power, retinal thickness, and visual field were examined. The association between near add power and ocular parameters and the odds ratios (ORs) for symptomatic presbyopia were investigated. Survival analysis for symptomatic presbyopia was conducted.

Results

Age, astigmatic power, mean deviation, and ganglion cell complex thickness were associated with near add power. The OR for symptomatic presbyopia was significant for age (OR = 1.51), astigmatism (OR = 1.01), mean deviation (OR = 0.72), ganglion cell complex thickness (OR = 0.98), treated and untreated glaucoma (OR = 2.09), and use of glaucoma eye drops (OR = 3.33). Survival analysis showed that the treated glaucoma group reached the near add power endpoint of ≥1.50 D (symptomatic presbyopia) significantly earlier than the other two groups, and there was no difference between the control and untreated glaucoma groups.

Conclusions

Glaucoma patients treated with eye drops may start near correction earlier.

Translational Relevance

Symptomatic presbyopia may develop earlier in patients with glaucoma, and our findings could further contribute to better management and understanding of presbyopia with glaucoma.

Real-World Clinical Results with the Hoya Vivinex Impress Intraocular Lens with Enhanced Depth of Focus

BACKGROUND

In cataract surgery, intraocular lenses (IOLs) with enhanced depth of focus are an option to correct presbyopia. The purpose of this quality assurance analysis was to evaluate visual acuity and patient satisfaction after implantation of the Hoya Vivinex Impress IOL.

METHODS

The Hoya Vivinex Impress IOL was implanted in patients undergoing cataract surgery at the Pallas Klinik, Olten, Switzerland. Five weeks postoperatively, a clinical examination and a survey on patient satisfaction were conducted.

RESULTS

A total of 17 eyes (9 patients; mean age 64 years) underwent cataract surgery with implantation of a Hoya Vivinex Impress IOL. Five weeks postoperatively, mean uncorrected distance visual acuity (UDVA) was 0.2 logMAR, uncorrected intermediate visual acuity (UIVA) was 0.0 logMAR, and uncorrected near visual acuity (UNVA) was 0.2 logMAR. The mean distance-corrected visual acuity results were 0.0 logMAR, 0.1 logMAR, and 0.3 logMAR, respectively. Reading the newspaper without glasses was possible for 33.4% of patients. Visual disturbances such as halos and glares were not reported.

CONCLUSION

Cataract surgery with Hoya Vivinex Impress IOL implantation revealed good distance and intermediate vision and, in some patients, functional near vision as well as a high patient satisfaction.

Visual Quality Assessment After FS-LASIK Using Customized Aspheric Ablation Profile for Age-Related Accommodation Deficiency Compensation

PURPOSE

To evaluate clinical outcomes and visual quality 12 months after femtosecond laser-assisted laser in situ keratomileusis (FS-LASIK) performed with the Custom-Q algorithm for correction of myopia with or without astigmatism and compensate for age-related accommodation deficiency.

METHODS

Patients who had Custom-Q FS-LASIK for myopia and myopic astigmatism with age-related accommodation deficiency were included in this retrospective study. Distance, intermediate, and near visual acuities, objective and subjective refractions, Q-factor, corneal higher order aberrations (HOAs), accommodation function, defocus curve, contrast sensitivity, and a subjective questionnaire assessing visual quality were evaluated 12 months postoperatively.

RESULTS

Clinical data of 43 cases were analyzed. The mean age was 42.02 ± 1.85 years (range: 40 to 48 years). At the 12-month follow-up visit, there were 43 (100%), 42 (97%), and 33 (77%) patients who achieved a binocular uncorrected distance, intermediate, and near visual acuity, respectively, better than 20/20 separately. Defocus curves revealed better distance vision in the dominant eyes, and the nondominant eyes performed better at intermediate and near vergence (P < .001). The Q-value and corneal spherical aberration coefficient were more positive in the dominant eyes than those in the nondominant eyes (P < .001). The accommodative amplitude and relative accommodation improved binocularly (P < .001). The questionnaire demonstrated high patient satisfaction with near vision, and no one reported having severe visual disturbance.

CONCLUSIONS

For myopic patients with age-related accommodation deficiency, the Custom-Q algorithm proved to be an effective way to achieve acceptable near vision without compromising distance vision. [J Refract Surg. 2024;40(4):e245-e252.].

Extract from Aronia melanocarpa, Lonicera caerulea, and Vaccinium myrtillus Improves near Visual Acuity in People with Presbyopia

Presbyopia is a global problem with an estimated 1.3 billion patients worldwide. In the area of functional food applications, dietary supplements or herbs, there are very few reports describing the positive effects of their use. In the available literature, there is a lack of studies in humans as well as on an animal model of extracts containing, simultaneously, compounds from the polyphenol group (in particular, anthocyanins) and iridoids, so we undertook a study of the effects of a preparation composed of these compounds on a condition of the organ of vision. Our previous experience on a rabbit model proved the positive effect of taking an oral extract of Cornus mas in stabilizing the intraocular pressure of the eye. The purpose of this study was to evaluate the effect of an orally administered ternary compound preparation on the status of physiological parameters of the ocular organ. The preparation contained an extract of the chokeberry Aronia melanocarpa, the honeysuckle berry Lonicera caerulea L., and the bilberry Vaccinium myrtillus (hereafter AKB) standardized for anthocyanins and iridoids, as bioactive compounds known from the literature. A randomized, double-blind, cross-over study lasting with a "wash-out" period of 17 weeks evaluated a group of 23 people over the age of 50, who were subjects with presbyopia and burdened by prolonged work in front of screen monitors. The group of volunteers was recruited from people who perform white-collar jobs on a daily basis. The effects of the test substances contained in the preparation on visual acuity for distance and near, sense of contrast for distance and near, intraocular pressure, and conjunctival lubrication, tested by Schirmer test, LIPCOF index and TBUT test, and visual field test were evaluated. Anthocyanins (including cyanidin 3-O-galactoside, delphinidin 3-O-arabinoside, cyanidin 3-O-glucoside, cyanidin 3-O-rutinoside, cyanidin 3-O-arabinoside) and iridoids (including loganin, sweroside, loganic acid) were identified as substances present in the extract obtained by HPLC-MS. The preliminary results showed that the composition of AKB applied orally does not change visual acuity in the first 6 weeks of administration. Only in the next cycle of the study was an improvement in near visual acuity observed in 92.3% of the patients. This may indicate potential to correct near vision in presbyopic patients. On the other hand, an improvement in conjunctival wetting was observed in the Schirmer test at the beginning of week 6 of administration in 80% of patients. This effect was weakened in subsequent weeks of conducting the experiment to 61.5%. The improvement in conjunctival hydration in the Schirmer test shows the potential beneficial effect of the AKB formulation in a group of patients with dry eye syndrome. This is the first study of a preparation based on natural, standardized extracts of chokeberry, honeysuckle berry, and bilberry. Preliminary studies show an improvement in near visual acuity and conjunctival hydration on the Schirmer test, but this needs to be confirmed in further studies.

Effects of Miosis on the Visual Acuity Space under Varying Conditions of Contrast and Ambient Luminance in Presbyopia

Background: Presbyopia is an age-related ocular condition, typically affecting individuals aged over 40 years, characterized by a gradual and irreversible decline in the eye's ability to focus on nearby objects. Correction methods for presbyopia encompass the use of corrective lenses, surgical interventions (corneal or lens based), and, more recently, the FDA-approved topical administration of 1.25% pilocarpine. While prior research has demonstrated the efficacy of daily pilocarpine eye drop application in enhancing near visual acuity by increasing the depth of focus leveraging the pinhole effect, limited knowledge exists regarding its influence on visual acuity under varying conditions of contrast and ambient luminance. Methods: This study aims to investigate the impact of these variables on visual acuity, employing the VA-CAL test, among 11 emmetropic and 11 presbyopic volunteers who reported subjective difficulties with near vision. This study includes evaluations under natural conditions with a pinhole occluder (diameter of 2 mm), and subsequent administration of 1% pilocarpine (Pilomann, Bausch + Lomb, Laval, Canada). Results: The VA-CAL results demonstrate the expected, statistically significant effects of contrast and ambient luminance on visual acuity in both emmetropic and presbyopic volunteers. Furthermore, in emmetropic individuals, the application of pilocarpine resulted in a statistically significant reduction in visual acuity. In contrast, presbyopes did not exhibit statistically significant differences in the visual acuity space under either the pinhole or pilocarpine conditions when compared to natural conditions. Conclusions: The pharmacological treatment of presbyopia with pilocarpine eye drops, intended to enhance near vision, does not adversely affect visual acuity in presbyopes. This suggests that pilocarpine may offer a viable alternative for individuals averse to wearing corrective eyewear.

Applications of SMILE-extracted lenticules in ophthalmology

AIM

To review recent innovations, challenges, and applications of small incision lenticule extraction (SMILE) extracted lenticule for treating ocular disorders.

METHODS

A literature review was performed in the PubMed database, which was last updated on 30 December 2021. There was no limit regarding language. The authors evaluated the reference lists of the collected papers to find any relevant research.

RESULTS

Due to the simplicity and accuracy of modern femtosecond lasers and the extensive development of SMILE surgery, many healthy human corneal stromal lenticules were extracted during surgery, motivating some professionals to investigate the SMILE lenticule reusability in different ocular disorders. In addition, new approaches had been developed to preserve, modify, and bioengineer the corneal stroma, leading to the optimal use of discarded byproducts such as lenticules from SMILE surgery. The lenticules can be effectively re-implanted into the autologous or allogenic corneas of human subjects to treat refractive errors, corneal ectasia, and corneal perforation and serve as a patch graft for glaucoma drainage devices with better cosmetic outcomes.

CONCLUSION

SMILE-extracted lenticules could be a viable alternative to human donor corneal tissue.

Patient Perception and Self-Reported Outcomes with Presbyopia-Correcting Intraocular Lenses (PCIOLs): A Social Media Listening Study

INTRODUCTION

Presbyopia-correcting intraocular lens (PCIOL) implantation is a popular treatment option for cataract surgery patients who desire spectacle independence. This study aimed to understand patient perception and outcomes with PCIOLs by analyzing patient social media posts.

METHODS

This was a non-interventional retrospective study that used predefined search strings to identify publicly available social media data discussing patient perceptions and outcomes with seven PCIOLs (three trifocal, one multifocal with continuous range of vision, and three extended depth-of-focus [EDOF] PCIOLs). Relevant posts were searched from Reddit, YouTube, and Facebook and patient forums Patient.info, Medicine.net, Optiker-Forum, and Medizin Forum from September 2020 to October 2022 in four languages (English, German, French, and Spanish).

RESULTS

A total of 2237 posts were included, all in English, with 68% of posts identified on Patient.info. The themes most discussed by patients were quality of vision (69% of total posts), patient experience after PCIOL implantation (30%), patient perception before PCIOL implantation (26%), and visual disturbances (24%). Most discussed PCIOLs were Vivity® (58% of total posts), PanOptix® (38%), Synergy® (26%), and Symfony® (13%). Patient perception of PCIOLs was most frequently influenced by healthcare professionals, online reading, and online videos (31%, 18%, and 15% of posts, respectively). A total of 215 posts (10% of total) discussed glasses use after PCIOL surgery: for EDOF and trifocal/multifocal PCIOLs, 37% and 56% of posts discussing glasses use stated being glasses free, respectively. A total of 537 posts discussed visual disturbances: halos/rings (66%) and starbursts (36%) were the most discussed visual disturbances for all lens types. Being glasses free after PCIOL implantation appeared to be a key driver of patient satisfaction.

CONCLUSION

Social media provides a rich source of information on patient perception, experience, and overall satisfaction of PCIOLs that can be used to complement and guide the collection of further evidence generated through controlled trials.

Alterations in Lens Free Water Distribution Are Associated with Shape Deformation in Accommodation

Objective

To investigate whether a redistribution of water within the crystalline lens is associated with the shape deformation that occurs during accommodation.

Design

Observational, cross sectional study.

Subjects

Eleven young adults without presbyopia (aged 18-39 years) and 9 middle-aged adults with presbyopia (aged 40-55 years).

Methods

Magnetic resonance imaging (MRI) scans of the lens were acquired on a 3 Tesla clinical MRI scanner, without and with the presentation of a 3 Diopter accommodative stimulus. The MRIs were postprocessed using established methods to extract the geometric dimensions and spatial maps of water distribution of the lens.

Main Outcome Measures

Accommodative changes in the full 3-dimensional description of lens shape, the lens total-water distribution profile, and the lens free-water distribution profile.

Results

Viewing of an accommodative stimulus by young subjects elicited an elastic shape deformation of the lens consistent with accommodation that was associated with an elevated, smoother free-water distribution, primarily in the anterior region of the lens. In contrast, viewing of an accommodative stimulus by presbyopic subjects produced an atypical shape deformation of the lens that was instead associated with a lowered free-water distribution, primarily in the anterior region of the lens. No discernible changes to the lens total-water distribution were observed in response to the accommodative stimulus in either subject cohort.

Conclusions

The present study suggests that protein-mediated alterations in the free-water distribution of the anterior region of the lens influence the shape deformation in accommodation, presenting pharmacological modulation of free-water distribution as an attractive novel approach for treating presbyopia.

Financial Disclosures

The authors have no proprietary or commercial interest in any materials discussed in this article.

Pilocarpine HCl 1.25% for treatment of presbyopia after laser vision correction: pooled analysis of two phase 3 randomized trials (GEMINI 1 and 2)

PURPOSE

To evaluate the efficacy of topical pilocarpine HCl 1.25% (Pilo) in treating presbyopia in individuals with or without a history of laser vision correction (laser-assisted in situ keratomileusis [LASIK] or photorefractive keratectomy [PRK]).

SETTING

Multiple clinical sites.

DESIGN

Pooled analysis of 2 identically designed prospective, randomized, vehicle-controlled studies (GEMINI 1 and 2).

METHODS

Adults aged 40 to 55 years with presbyopia received once-daily Pilo or vehicle bilaterally for 30 days. Responder rates for ≥3-line improvement in mesopic, high-contrast, binocular distance-corrected near visual acuity (DCNVA) were determined on day 30.

RESULTS

Among participants with a history of LASIK/PRK (n = 39 in the Pilo group, n = 41 in the vehicle group), responder rates for ≥3-line improvement in DCNVA on day 30 at hours 0.25, 0.5, 1, 3, 6, 8, and 10, respectively, were 16.7%, 38.9%, 41.7%, 37.8%, 16.2%, 13.9%, and 8.3% with Pilo and 0.0%, 2.6%, 10.5%, 5.1%, 7.7%, 2.6%, and 0.0% with vehicle. Responder rates in the LASIK/PRK subgroup were significantly higher with Pilo than vehicle at hours 0.25 ( P = .0087), 0.5 ( P = .0001), 1 ( P = .0022), and 3 ( P = .0005). In contrast, there were no significant differences in responder rates between Pilo-treated participants with and without LASIK/PRK. Among non-LASIK/PRK participants in the Pilo group (n = 336), responder rates for ≥3-line improvement in DCNVA on day 30 at hours 0.25, 0.5, 1, 3, 6, 8, and 10, respectively, were 16.8%, 32.7%, 39.0%, 28.0%, 17.4%, 12.6%, and 10.5%.

CONCLUSIONS

Pilo treatment effectively and similarly improved DCNVA in presbyopes with or without a history of laser vision correction.

Factors influencing the need and willingness for presbyopic correction: a cross sectional study from south India

Presbyopia is an age-related physiological phenomenon in which eye gradually losses its ability to accommodate. It is one of the leading causes of visual impairment worldwide, especially in adults above the age of 40. If uncorrected, it can significantly impair a patient's quality of life. This study aims to evaluate the factors which affects patient's need and willingness to accept presbyopic correction. This cross-sectional analytical study was carried out in a semi urban tertiary care hospital from Jan 2021 to June 2022 among patients aged 40 and above who presented to Outpatient department (OPD). Demographic details, medical history, presenting ocular complaints pertaining to presbyopia, spectacle use and decision regarding using near vision correction were noted. Ocular examination included refraction and ocular biometry. Factors that may have influenced complaints of presbyopia or willingness to accept presbyopic correction were analysed. Three hundred and forty two patients with a mean age of 48.55 ± 6.68 years were included. Of these, 262 (76.61%) patients presented with chief complaints related to presbyopia. Those with higher educational qualification (p = 0.031), hypermetropia (p = 0.021), shallower AC depth (p = 0.028) and on medications for systemic ailments (p = 0.01), were more likely to present with chief complaints attributable to presbyopia. Among them, those with higher educational qualifications (p = 0.02) and skilled workers were more likely to accept near vision glasses (p = 0.02), while those with lower Hb (p = 0.01) and myopia (p = 0.01) were less likely to accept correction for presbyopia. Among the 80 patients without chief complaints related to presbyopia, 35 (43.75%) were not willing to accept near vision glasses. Those with higher BMI (p = 0.04) and hypermetropes (p = 0.05) were more willing to accept presbyopic correction. Presbyopia constitutes a significant reason for patients above the age of 40 visiting eye care facility. Multiple socio-economic, systemic and ocular factors influenced both the chief complaints related to presbyopia and willingness to accept presbyopic correction.

Defocus Curve and Satisfaction of Patients with Presbyopia After LASIK Using the Differential Modulation of Binocular Longitudinal Spherical Aberration

Purpose

To investigate the visual acuity and satisfaction of patients after Zhang & Zheng's corneal laser-enhanced accommodation refraction Q (ZZ-CLEAR-Q) surgery utilizing differential modulation of binocular longitudinal spherical aberration and determine its clinical significance.

Patients and Methods

This prospective observational study enrolled a consecutive cohort of patients with presbyopia who underwent ZZ-CLEAR-Q surgery between December 2020 and January 2023. The study assessed visual acuity, distance-corrected defocus curve, satisfaction, Q factor, manifest spherical equivalent, and primary spherical aberration, among others, at 3 months postoperatively. Additionally, the study conducted a binocular comparison to analyze the clinical significance of setting the different longitudinal spherical aberrations.

Results

A total of 232 eyes of 116 patients were included. The binocular uncorrected distance visual acuity was 20/20 for all patients. At 3 months postoperatively, the binocular uncorrected near visual acuity was Jaeger 1 for 96% of the patients and Jaeger 2 for 100% of the patients. Furthermore, 93.1% of the patients expressed satisfaction. The monocular distance-corrected defocus curve revealed that the dominant eyes had significantly better visual acuity at 0 D (P<0.001), while the non-dominant eyes had significantly better visual acuity across various defocus levels except 0 and -0.50 D (All P<0.05). At 3 months, there were no significant differences between the expected and achieved manifest spherical equivalents, corneal Q factor values, and ocular primary spherical aberration values of both groups.

Conclusion

Patients with presbyopia who underwent ZZ-CLEAR-Q surgery were likely to achieve normal uncorrected visual acuity and be satisfied. The increased depth of field has clinical significance for assisting near vision.

Topical ocular application of aggrelyte-2A reduces lens stiffness in mice

Presbyopia is the progressive loss of the ability of the lens to focus on nearby objects due to its increased stiffness. It occurs in the mid-40s and continues to worsen until the mid-60s. The age-associated increase in protein cross-linking in the lens leads to protein aggregation and water insolubility, especially in the nuclear region, contributing to lens stiffness. This study reports the development of aggrelyte-2A (methyl S-acetyl-N-(3,3-dimethylbutanoyl) cysteinate, a derivative of our previously reported aggrelyte-2) for reversing the stiffness of aged lenses. Aggrelyte-2A showed minimal toxicity in cultured mouse lens epithelial cells (up to 2000 µM) and human lens epithelial cells (up to 250 µM). Lenses from aged mice (age: 24-25 months) treated with 1 mM aggrelyte-2A for 24 h, and human lenses (age: 47-67 years) treated with 250 µM aggrelyte-2A for 48 h showed 11-14% reductions in stiffness, accompanied by an increase in acetyllysine in lens proteins, and free-thiols in the lens. Topical application of aggrelyte-2A (40 mM, 5 µl twice daily for 4 weeks) on mouse eyes significantly reduced lens stiffness. The topical application showed no toxicity to the lens, cornea, or retina, as revealed by morphological examination, H&E staining, and optical coherence tomography. These data suggest that aggrelyte-2A could be developed as a presbyopia-reversing therapeutic.

Adenosine Triphosphate (ATP) and Protein Aggregation in Age-Related Vision-Threatening Ocular Diseases

Protein aggregation is the etiopathogenesis of the three most profound vision-threatening eye diseases: age-related cataract, presbyopia, and age-related macular degeneration. This perspective organizes known information on ATP and protein aggregation with a fundamental unrecognized function of ATP. With recognition that maintenance of protein solubility is related to the high intracellular concentration of ATP in cells, tissues, and organs, we hypothesize that (1) ATP serves a critical molecular function for organismal homeostasis of proteins and (2) the hydrotropic feature of ATP prevents pathological protein aggregation while assisting in the maintenance of protein solubility and cellular, tissue, and organismal function. As such, the metabolite ATP plays an extraordinarily important role in the prevention of protein aggregation in the leading causes of vision loss or blindness worldwide.

Assessment of Visual Habituation Measured With the Halo & Glare Simulator and Its Impact on Patient Satisfaction Following Quadrifocal IOL Implantation

PURPOSE

To evaluate the levels of habituation and its influence on outcome satisfaction in patients who underwent bilateral multifocal intraocular lens (IOL) implantation.

METHODS

A total of 24 patients underwent bilateral multifocal IOL implantation surgery with the AcrySof IQ PanOptix trifocal diffractive IOL (Alcon Laboratories, Inc) following cataract extraction or for refractive purposes. Data were collected 3 and 6 months after surgery, which included subjective refraction, corrected and uncorrected visual acuity (distance, intermediate, near), a contrast sensitivity test, simulation with the Halo & Glare Simulator (Carl Zeiss Meditec AG), two visual quality surveys, and a slit-lamp examination by an ophthalmologist.

RESULTS

All patients were spectacle independent for distance vision and 92% (n = 22) needed no visual aid for near vision. Minor visual acuity improvement was detected between both examinations at monocular uncorrected distance visual acuity (P = .025). Improvements of presence, size, and intensity of visual disturbances were not statistically significant, but overall patient satisfaction (P = .009) and Weber-Contrast sensitivity under mesopic conditions (P = .029) increased significantly.

CONCLUSIONS

Diffractive multifocal IOLs are a stable treatment for presbyopia and/or cataract with a high spectacle independence rate. Visual disturbances caused by their optics do not decrease significantly between 3 and 6 months after surgery. Habituation and neuroadaptation play a significant role in patient satisfaction and contrast sensitivity during and possibly beyond that period. [J Refract Surg. 2023;39(8):510-517.].

Rotational stability and refractive outcomes of the DFT/DATx15 toric, extended depth of focus intraocular lens

PURPOSE

To quantitatively assess postoperative rotational stability and visual acuity with the DFT/DATx15 extended depth of focus (EDOF) toric intraocular lens (IOL).

METHODS

In this prospective case series, thirty-five patients with a calculated IOL power between + 15.0 D and + 25.0 D, corneal astigmatism between 0.75 D and 2.25 D, and no significant ocular pathology underwent cataract surgery. Primary outcome was rotational stability of the IOL at 1 month post-operatively. Secondary outcomes included residual refractive astigmatism, absolute residual astigmatism prediction error, and monocular distance and intermediate visual acuities.

RESULTS

Mean absolute postoperative IOL rotation was 1.1 ± 0.2 degrees, with no rotation of more than 3 degrees at the final visit. Monocular mean best spectacle-corrected distance visual acuity (BSCDVA) improved from logMAR 0.27 ± 0.030 to 0.078 ± 0.017 (P < .001). Monocular uncorrected distance visual acuity (UCDVA) improved from 0.93 ± 0.096 to 0.18 ± 0.022 (P < .001). Best spectacle-corrected intermediate visual acuity (DSCIVA) was 0.17 ± 0.025, and uncorrected intermediate visual acuity (UCIVA) was 0.27 ± 0.040. Residual regular astigmatic refractive error was 0.21 ± 0.047 D.

CONCLUSIONS

The toric DFT/DATx15 EDOF lens showed excellent rotational stability and effective and predictable correction of astigmatism. Its refractive outcomes and safety profile were similar to those identified in prior studies of the non-toric DFT/DAT015 EDOF IOL. A small difference in monocular BSCDVA, of uncertain clinical significance, was found when comparing these outcomes with prior DFT/DAT015 data. The trial was retrospectively registered on November 5, 2021 (TRN ​​NCT05119127).

Refractive lens exchange - who is getting it, what are they getting, how are they doing?

PURPOSE OF REVIEW

The purpose of this article is to provide a review of the literature on refractive lens exchange and present a retrospective analysis of 55 patients who underwent refractive lens exchange at a single practice.

RECENT FINDINGS

Our study substantiates refractive lens exchange as an important option for presbyopic patients, hyperopic patients or patients with extremely high refractive error who desire spectacle independence.

SUMMARY

Our study reveals that the refractive lens exchange population is younger than the average cataract population and their primary motivations are to resolve hyperopic or myopic refractive errors, gain spectacle independence, and address near vision loss. A variety of presbyopia-addressing intraocular lens options are available and we present our experience with multifocal, extended depth-of-focus, light-adjustable, and monofocal lenses.

Refractive-type varifocal liquid-crystal Fresnel lenses for smart contacts

We demonstrate the implementation of a low-power, low-profile, varifocal liquid-crystal Fresnel lens stack suitable for tunable imaging in smart contact lenses. The lens stack consists of a high-order refractive-type liquid crystal Fresnel chamber, a voltage-controlled twisted nematic cell, a linear polarizer and a fixed offset lens. The lens stack has an aperture of 4 mm and thickness is ∼980 µm. The varifocal lens requires ∼2.5 V_RMS for a maximum optical power change of ∼6.5 D consuming electrical power of ∼2.6 µW. The maximum RMS wavefront aberration error was 0.2 µm and the chromatic aberration was 0.008 D/nm. The average BRISQUE image quality score of the Fresnel lens was 35.23 compared to 57.23 for a curved LC lens of comparable power indicating a superior Fresnel imaging quality.

Topical Application of Deglycating Enzymes as an Alternative Non-Invasive Treatment for Presbyopia

Presbyopia is an age-related vision disorder that is a global public health problem. Up to 85% of people aged ≥40 years develop presbyopia. In 2015, 1.8 billion people globally had presbyopia. Of those with significant near vision disabilities due to uncorrected presbyopia, 94% live in developing countries. Presbyopia is undercorrected in many countries, with reading glasses available for only 6-45% of patients living in developing countries. The high prevalence of uncorrected presbyopia in these parts of the world is due to the lack of adequate diagnosis and affordable treatment. The formation of advanced glycation end products (AGEs) is a non-enzymatic process known as the Maillard reaction. The accumulation of AGEs in the lens contributes to lens aging (leading to presbyopia and cataract formation). Non-enzymatic lens protein glycation induces the gradual accumulation of AGEs in aging lenses. AGE-reducing compounds may be effective at preventing and treating AGE-related processes. Fructosyl-amino acid oxidase (FAOD) is active on both fructosyl lysine and fructosyl valine. As the crosslinks encountered in presbyopia are mainly non-disulfide bridges, and based on the positive results of deglycating enzymes in cataracts (another disease caused by glycation of lens proteins), we studied the ex vivo effects of topical FAOD treatment on the power of human lenses as a new potential non-invasive treatment for presbyopia. This study demonstrated that topical FAOD treatment resulted in an increase in lens power, which is approximately equivalent to the correction obtained by most reading glasses. The best results were obtained for the newer lenses. Simultaneously, a decrease in lens opacity was observed, which improved lens quality. We also demonstrated that topical FAOD treatment results in a breakdown of AGEs, as evidenced by gel permeation chromatography and a marked reduction in autofluorescence. This study demonstrated the therapeutic potential of topical FAOD treatment in presbyopia.

Aggrelyte-2 promotes protein solubility and decreases lens stiffness through lysine acetylation and disulfide reduction: Implications for treating presbyopia

Aging proteins in the lens become increasingly aggregated and insoluble, contributing to presbyopia. In this study, we investigated the ability of aggrelyte-2 (N,S-diacetyl-L-cysteine methyl ester) to reverse the water insolubility of aged human lens proteins and to decrease stiffness in cultured human and mouse lenses. Water-insoluble proteins (WI) of aged human lenses (65-75 years) were incubated with aggrelyte-2 (500 μM) for 24 or 48 h. A control compound that lacked the S-acetyl group (aggrelyte-2C) was also tested. We observed 19%-30% solubility of WI upon treatment with aggrelyte-2. Aggrelyte-2C also increased protein solubility, but its effect was approximately 1.4-fold lower than that of aggrelyte-2. The protein thiol contents were 1.9- to 4.9-fold higher in the aggrelyte-2- and aggrelyte-2C-treated samples than in the untreated samples. The LC-MS/MS results showed Nε -acetyllysine (AcK) levels of 1.5 to 2.1 nmol/mg protein and 0.6 to 0.9 nmol/mg protein in the aggrelyte-2- and aggrelyte-2C-treated samples. Mouse (C57BL/6J) lenses (incubated for 24 h) and human lenses (incubated for 72 h) with 1.0 mM aggrelyte-2 showed significant decreases in stiffness with simultaneous increases in soluble proteins (human lenses) and protein-AcK levels, and such changes were not observed in aggrelyte-2C-treated lenses. Mass spectrometry of the solubilized protein revealed AcK in all crystallins, but more was observed in α-crystallins. These results suggest that aggrelyte-2 increases protein solubility and decreases lens stiffness through acetylation and disulfide reduction. Aggrelyte-2 might be useful in treating presbyopia in humans.

Non-Miotic Improvement in Binocular Near Vision with a Topical Compound Formula for Presbyopia Correction

INTRODUCTION

The aim of this case series was to examine the association between unaided binocular visual acuity for near vision and pupil change after the instillation of a special topical formulation for presbyopia treatment.

METHODS

This was a case series consisting of consecutive participants with presbyopia aged 40-70 years who were tested for visual acuity and pupil diameter before and 2 h after instillation of a formulation of pilocarpine and phenylephrine drops (FOV Tears) for presbyopia. Participants underwent subjective refraction, photopic and scotopic pupil diameter measurement and unaided monocular and binocular visual acuity testing by logMAR for distance and near vision both pre- and post-instillation of eye drops.

RESULTS

The study enrolled 363 subjects (n = 176 women, 48%) with a mean (± standard deviation) age of 50.4 ± 5.8 years. Mean spherical equivalent (SE) changed significantly (- 0.17 Diopters) after instillation of the FOV Tears formulation (p < 0.001). Post-instillation of eye drops, the scotopic pupil diameter decreased by 0.97 ± 0.98 mm, and the near visual acuity by logMAR improved significantly by nearly two lines (p < 0.01). In the linear regression analyses, age (p < 0.001) and SE pre-drop instillation (p < 0.001) were associated with unaided binocular visual acuity. The changes in photopic pupil diameter and the scotopic pupil diameter were not associated with unaided binocular visual acuity.

CONCLUSIONS

The use of the pilocarpine and phenylephrine formulation (FOV Tears) improved binocular visual acuity for near vision in presbyopic patients, and the effect was independent of pupil change.

Nutraceuticals: A Promising Therapeutic Approach in Ophthalmology

Oxidative stress represents one of the main factors driving the pathophysiology of multiple ophthalmic conditions including presbyopia, cataracts, dry eye disease (DED), glaucoma, age-related macular degeneration (AMD) and diabetic retinopathy (DR). Currently, different studies have demonstrated the role of orally administered nutraceuticals in these diseases. For instance, they have demonstrated to improve lens accommodation in presbyopia, reduce protein aggregation in cataracts, ameliorate tear film stability, break up time, and tear production in dry eye, and participate in the avoidance of retinal neuronal damage and a decrease in intraocular pressure in glaucoma, contribute to the delayed progression of AMD, or in the prevention or treatment of neuronal death in diabetic retinopathy. In this review, we summarized the nutraceuticals which have presented a positive impact in ocular disorders, emphasizing the clinical assays. The characteristics of the different types of nutraceuticals are specified along with the nutraceutical concentration used to achieve a therapeutic outcome in ocular diseases.

Correction of presbyopia

Presbyopia, a progressive visual difficulty caused by weakened physiological regulation, is one of the main causes of visual impairment in people over 40 years old. Currently, the main methods of correction of presbyopia include optical correction, surgical correction, and drug treatment, which can improve the visual nearness disorder to some extent. Optical correction is the most common way with advantages of safety, which can adjust the lens parameters at any time, while cause kinds of inconvenience in life by wearing and taking off glasses frequently. Surgical intervention, including corneal surgery, lens surgery and scleral surgery, with certain advantages and disadvantages in each operation style. New pharmaceutical agents are expected to be a new and effective method for the treatment of presbyopia, but it lacks multicenter randomized controlled trials and evidence-based medicine evidence to evaluate the safety and effectiveness.

Review of Presbyopia Treatment with Corneal Inlays and New Developments

Presbyopia may represent the largest segment of refractive errors that is without an established and effective refractive surgery treatment. Corneal Inlays are materials (synthetic or allogenic) implanted in the stroma of patients’ corneas to improve presbyopia. These inlays, introduced into the United States in 2015 via the small-aperture corneal inlay (KAMRA^TM, SightLife Surgical/CorneaGen, Seattle, Washington, United States), were met with an initial wave of enthusiasm. Subsequent models like the shape-changing corneal inlay (RAINDROP^TM, Revision Optics, Lake Forest, California, United States) offered excellent results for patients, but longer-term research raised questions about patient safety. At the time of this article, no synthetic corneal inlays are available in the United States for the correction of presbyopia. Other options for presbyopia correction include allograft corneal inlays, trifocal synthetic corneal inlays, pharmacologic therapies, scleral incisions or additive techniques and PresbyLASIK. Presently, allograft inlays consist of corneal lenticules removed from patients undergoing Small Incision Lenticule Extraction (SMILE). We will review corneal inlays and other alternative procedures that may provide effective and predictable treatments for patients with presbyopia.

Treatment and prevention of pathological mitochondrial dysfunction in retinal degeneration and in photoreceptor injury

Pathological deterioration of mitochondrial function is increasingly linked with multiple degenerative illnesses as a mediator of a wide range of neurologic and age-related chronic diseases, including those of genetic origin. Several of these diseases are rare, typically defined in the United States as an illness affecting fewer than 200,000 people in the U.S. population, or about one in 1600 individuals. Vision impairment due to mitochondrial dysfunction in the eye is a prominent feature evident in numerous primary mitochondrial diseases and is common to the pathophysiology of many of the familiar ophthalmic disorders, including age-related macular degeneration, diabetic retinopathy, glaucoma and retinopathy of prematurity - a collection of syndromes, diseases and disorders with significant unmet medical needs. Focusing on metabolic mitochondrial pathway mechanisms, including the possible roles of cuproptosis and ferroptosis in retinal mitochondrial dysfunction, we shed light on the potential of α-lipoyl-L-carnitine in treating eye diseases. α-Lipoyl-L-carnitine is a bioavailable mitochondria-targeting lipoic acid prodrug that has shown potential in protecting against retinal degeneration and photoreceptor cell loss in ophthalmic indications.

Pilocarpine 1.25% and the changing landscape of presbyopia treatment

PURPOSE OF REVIEW

Despite affecting approximately 1.8 billion individuals worldwide, until recently, a pharmacologic treatment for presbyopia was not available. This special commentary reviews the treatment of presbyopia with a focus on the recently approved medication Vuity (pilocarpine 1.25%, Allergan, an AbbVie Company).

RECENT FINDINGS

Vuity is a re-engineered formulation of pilocarpine 1.25% specifically designed for the treatment of presbyopia. Recently published results from the GEMINI 1 Phase 3 clinical trial reported improvement in distance corrected near vision without significant compromise in distance vision. No unexpected safety findings were reported with mild headache being the most common adverse event. Notably, there were no reported cases of retinal detachment or angle closure during the 30-day phase 3 clinical trials.

SUMMARY

Vuity is the first treatment designed and FDA approved to treat the growing presbyopia market. Phase 3 clinical trials demonstrated its ability to improve near vision without significant compromise in distance vision. We recognize this paradigm shift in the treatment of presbyopia and anxiously await additional treatment options for this ubiquitous condition.

An AFM Approach Applied in a Study of α-Crystallin Membrane Association: New Insights into Lens Hardening and Presbyopia Development

The lens of the eye loses elasticity with age, while α-crystallin association with the lens membrane increases with age. It is unclear whether there is any correlation between α-crystallin association with the lens membrane and loss in lens elasticity. This research investigated α-crystallin membrane association using atomic force microscopy (AFM) for the first time to study topographical images and mechanical properties (breakthrough force and membrane area compressibility modulus (K_A), as measures of elasticity) of the membrane. α-Crystallin extracted from the bovine lens cortex was incubated with a supported lipid membrane (SLM) prepared on a flat mica surface. The AFM images showed the time-dependent interaction of α-crystallin with the SLM. Force spectroscopy revealed the presence of breakthrough events in the force curves obtained in the membrane regions where no α-crystallin was associated, which suggests that the membrane’s elasticity was maintained. The force curves in the α-crystallin submerged region and the close vicinity of the α-crystallin associated region in the membrane showed no breakthrough event within the defined peak force threshold, indicating loss of membrane elasticity. Our results showed that the association of α-crystallin with the membrane deteriorates membrane elasticity, providing new insights into understanding the molecular basis of lens hardening and presbyopia.

Living with presbyopia: experiences from a virtual roundtable dialogue among impacted individuals and healthcare professionals

BACKGROUND

Presbyopia is a common progressive vision disorder characterised by an inability to focus on near objects. The emergence of newer treatment options in addition to spectacles or contact lenses highlights the importance of assessing patient/user preferences.

METHODS

People with presbyopia and healthcare professionals (HCPs) took part in a moderated, structured discussion of specific questions on a virtual advisory-board platform. The objective was to better understand unmet needs and the experience of living with the condition. Closed and open questions were included.

RESULTS

Nine individuals (age 40 to 70 years) with presbyopia participated, from Australia, China, France, Italy, Ireland, Japan and the US. One ophthalmologist and one optometrist represented the perspective of HCPs. Over two weeks, 621 posts were entered on the platform. There was widespread agreement that the often stated association between age and presbyopia was unfortunate. Some participants had developed presbyopia at 30-45 years of age. What is more, the association with age was seen as implying a natural process, reducing the incentive to treat. Instead there was a call for an action-oriented view of presbyopia as a condition which may be effectively treated in the future. All participants experienced dealing with presbyopia as burdensome, affecting quality of life to varying degrees. When considering new treatments, convenience was the most important factor. The option to administer drops when needed was considered favourable, but short-acting treatments may not reduce inconvenience compared with spectacles. Participants viewed a therapy that targets the underlying cause of the condition favourably compared with symptomatic treatment. Side effects would severely reduce the appeal of drops. For clinical trials in presbyopia, patient-reported outcomes should be mandatory and need adequately to capture quality of life. Studies in presbyopia must be designed to minimise the inconvenience to participants in order to counter the risk of high drop-out rates.

CONCLUSIONS

The interactive format provided insights into living with presbyopia, particularly the negative impact on quality of life, subjects' openness to new therapies, and the need to move away from considering the condition an unavoidable and intractable consequence of ageing.

Membrane elasticity modulated by cholesterol in model of porcine eye lens-lipid membrane

Experimental evidence shows that the eye lens loses its elasticity dramatically with age. It has also been reported that the cholesterol (Chol) content in the eye lens fiber cell plasma membrane increases significantly with age. High Chol content leads to the formation of cholesterol bilayer domains (CBDs) in the lens membrane. The role of high Chol associated with lens elasticity is unclear. The purpose of this research is to investigate the membrane elasticity of the model of porcine lens-lipid (MPLL) membrane with increasing Chol content to elucidate the role of high Chol in lens membrane elasticity. In this study, we used atomic force microscopy (AFM) to study the mechanical properties (breakthrough force and area compressibility modulus (K_A)) of the MPLL membrane with increasing Chol content where K_A is the measure of membrane elasticity. We varied Chol concentration in Chol/MPLL membrane from 0 to ∼71 mol%. Supported Chol/MPLL membranes were prepared by fusion of small unilamellar vesicles (SUVs) on top of a flat mica surface. SUVs of the Chol/MPLL lipid mixture were prepared with the rapid solvent exchange method followed by probe-tip sonication. For the Chol/MPLL mixing ratio of 0, AFM image showed the formation of two distinct phases of the membrane, i.e., liquid-disordered phase (l_d) and solid-ordered phase (s_o) membrane. However, with Chol/MPLL mixing ratio of 0.5 and above, only liquid-ordered phase (l_o) membrane was formed. Also, two distinct breakthrough forces corresponding to l_d and s_o were observed for Chol/MPLL mixing ratio of 0, whereas only one breakthrough force was observed for membranes with Chol/MPLL mixing ratio of 0.5 and above. No significant difference in the membrane surface roughness was measured with increasing Chol content for these membranes; however, breakthrough force and K_A for l_o membrane increased when Chol/MPLL mixing ratio was increased from 0.5 to 1. Interestingly above the Chol/MPLL mixing ratio of 1, both breakthrough force and K_A decreased, indicating the formation of CBDs. Furthermore, these results showed that membrane elasticity increases at high Chol content, suggesting that high Chol content in lens membrane might be responsible for maintaining lens membrane elasticity.

Pharmacological Treatment in Presbyopia

Pharmacological treatment of presbyopia may be an alternative for those who want a spectacle-free scenario and an easy-to-use method with lower risk of irreversible ocular adverse events. There are two main agents, miotics and lens softeners, investigated as agents for the pharmacological treatment. Miotic agents treat presbyopia by creating a pinhole effect which may increase the depth of focus at all working distances. The miotic agents have been studied for application to only one eye for monovision or both eyes. Their effect is temporary with common adverse events, such as headache and dim vision at nighttime, with no known long-term safety and efficacy. There have been studies on the miotic agents in combination with other agents for additive treatment effects or lessening adverse events, however, these combination effects are not clear. Lens softeners increase the elasticity of the lens, which is targeted at one of the etiologic mechanisms of presbyopia. There is only one lens softener being investigated in only a few trials. The results were inconclusive. The recent approval of 1.25% pilocarpine for treatment of presbyopia by the US FDA may be an important milestone for investigation of real-world data of pharmacological treatment of presbyopia.

A Biomechanical Model for Evaluating the Performance of Accommodative Intraocular Lenses

Accommodation alters the shape of the eye lens to change focus from distant to near vision. This function declines with age in the development of presbyopia and most people experience a near total loss of accommodative ability by 55 years. Currently, there are no surgical procedures that correct presbyopia, but considerable work has been done in the development of accommodative intraocular lenses (AIOLs) implanted during cataract surgery. Despite these efforts, AIOLs only restore ∼ 20% of youthful accommodative amplitude and they suffer from high rates of visually-debilitating fibrosis. An important design tool that is lacking that could aid in improving AIOL designs is modeling. Herein, we addressed this need through the development of a fully 3-D finite element model that was used to predict the behavior of a dual-optic AIOL implanted within the post-surgical lens capsule. Models of the native human lens were developed to identify the stress-free configuration of the lens capsule needed to accurately predict the accommodated state of the lens and the configuration of the zonular traction needed for the disaccommodated state. The AIOL model demonstrated the functional importance of implant stiffness and predicted an approximately linear relationship between zonular traction magnitude and axial displacement of the optics. To our knowledge, this is the first model that can be used to gain insights into AIOL efficacy. It provides a foundation for continued development of a predictive tool that could ultimately improve AIOL designs that seek to restore youthful accommodative function.