John A. Hovanesian, MD, FACS, focuses his blog on real-world comanagement cases with valuable take-home messages. Dr. Hovanesian is a specialist in cornea, external ocular disease and refractive and cataract surgery with Harvard Eye Associates in Laguna Hills, Calif., a clinical instructor at UCLA Jules Stein Eye Institute and a member of the Primary Care Optometry News Editorial Board.

BLOG: Embrace newer presbyopia therapies

They say there are four stages of life. First, you believe in Santa Claus. Then, you don’t believe in Santa Claus. Next, you are Santa Claus. Finally, you begin to look like Santa Claus.

As I hover between stages 3 and 4, I realize how true this adage is and how real a challenge presbyopia is for those of us who experience it.

Let’s face it: Presbyopia stinks. It constantly reminds us that we are at least in stage 3 and forces us to adopt some type of optical correction. Yet available surgical treatments for presbyopia force us to choose between monovision and poor optics.

Multifocal lens implants, good as they are, compromise contrast. Accommodating implants still require some degree of monovision. While these are the most common and trusted forms of presbyopia correction, they are also the most invasive and least reversible, and neither is a great choice for the younger emmetropic presbyope.

Several promising new offerings for presbyopes are or will soon be available for the younger emmetrope. Miotic eye drops that increase accommodation and those that shift the fluid dynamics of the lens are showing promising results in mid-stage FDA trials. In one product offered by Presbyopia Therapies, aceclidine, a mild parasympathomimetic agent used overseas for narrow-angle glaucoma, is mixed with a mild cycloplegic agent. This seems to modulate the pupil diameter to about 1.7 mm — ideal for maximizing depth of field. Another company, Encore Vision, is producing a compound designed to shift the fluid dynamics in the crystalline lens, allowing some restoration of accommodation.

Scleral expansion bands are an old idea that is being updated by the company Refocus Group. This cleverly redesigned the old implants placed in a scleral pocket, making their positioning more predictable and secure. The result: more consistent and sustained accommodation with more tolerable surgical implants than the old designs that fell out of favor. We should watch closely this company’s results as it moves through the FDA approval process.

Finally, two corneal inlays are already approved in the U.S. for treating presbyopia: the AcuFocus Kamra and the ReVision Optics Raindrop. While early adoption by surgeons has been slow, many believe that increasing public awareness and surgeon acceptance will drive these to be a mainstream therapy for the young stage 3’er.

Many younger emmetropic presbyopes don’t adapt to monovision or aren’t willing to try. What’s odd about the remaining options is that the most noninvasive and reversible treatments (drops that enhance focus and scleral expansion bands) are the least trusted, while the most invasive and irreversible treatments (IOLs) are the most widely used.

As a fellow refractive surgeon and stage 3/4 presbyope, I hope all clinicians will embrace and help refine newer presbyopia therapies. Our patients need them. Have a little pity on Santa Claus, will ya?

Disclosure: Hovanesian reports he is a consultant to Alcon, Abbott Medical Optics, Bausch + Lomb and ReVision Optics.

Editor’s note: ReVision Optics, maker of the Raindrop near vision inlay, went out of business and stopped selling the product Jan. 30.