Presbyopia

Aka: Presbyopia, Muscarinic Agonists for Presbyopia, Vuity, Qlosi, Vizz, Yuvezzi

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II. Definitions

  1. Presbyopia
    1. Age-related loss of accommodation

III. Epidemiology

  1. Onset after age 45 to 60 years old

IV. Mechanism

  1. Crystalline lens loses elasticity with normal aging
  2. Accommodation is less effective
    1. Lens no longer thickens on ciliary Muscle Contraction (near Vision, reading distance)

V. Symptoms

  1. Blurred Vision on reading fine print
  2. Eye strain and Headache may occur

VI. Management: Correction

  1. Glasses or Contact Lens
    1. Single-Vision reading glasses (inexpensive $20, OTC)
    2. Bifocal glasses (clear far distance and reading distance)
    3. Trifocal glasses (clear far distance, middle distance such as a computer screen, and reading distance)
    4. Multifocal glasses (no-line lenses, with continuous range of correction for various distances)
  2. Monovision
    1. One eye corrected for near Vision
    2. Other eye corrected for distance Vision

VII. Management: Muscarinic Agonists

  1. Background
    1. Muscarinic Agonists constrict the pupil (or prevent its dilation) resulting in Miosis
    2. Miosis may sharpen and extend the depth of focus, similar to a pinhole camera
    3. Medications do not affect Presbyopia progression
    4. Cost: $70-80 to $120/month in 2026
  2. Dosing
    1. Onset of action within 15-30 minutes of instillation
    2. Separate instillation of other eye medications by at least 5 minutes
    3. Wait at least 10 minutes before inserting Contact Lenses
  3. Adverse Effects
    1. Headache
    2. Limits night Vision
      1. Avoid night driving after instilling drops (otherwise use a shorter-acting agent)
    3. Retinal Detachment risk (rare)
      1. Dilated Eye Exam is recommended before using Muscarinic Agonists
      2. Warn patients to be evaluated immediately for acute Light Flashes and Floaters
  4. Pilocarpine 1.25% (Vuity)
    1. Dose: One drop per eye once daily
    2. Duration: 6 hours
    3. Non-Selective Muscarinic Agonist
    4. May store at room Temperature
    5. Contains preservative (benzalkonium chloride)
  5. Pilocarpine 0.4% (Qlosi)
    1. Dose 1 drop in each eye, and may repeat once in 2-3 hours
      1. Manufacturer recommends twice daily dosing for the first week
    2. Duration: 8 hours after 2 doses
    3. Non-Selective Muscarinic Agonist
    4. Preservative-free
        1. Store in refrigerator
  6. Aceclidine 1.44% (Vizz)
    1. Daily Dose: One drop in each eye, then repeat again in 2 min with a second drop in each eye
    2. Duration: 10 hours
    3. Selective Muscarinic Agonist
    4. Preservative-free
    5. Best stored in refrigerator (may be left at room Temperature for up to 30 days)
  7. Carbachol 2.75%/Brimonidine 0.1% (Yuvezzi)
    1. Dose: One drop per eye once daily
    2. Duration: 10 hours
    3. May be stored at room Temperature
    4. Preservative-free
    5. Non-Selective Muscarinic Agonist AND alpha-Adrenergic Agonist (Brimonidine) combination
      1. Alpha-Adrenergic Agonist (Brimonidine) may interact with Antihypertensives and worsen raynauds phenomenon
  8. References
    1. (2022) presc lett 29(1): 1-2
    2. (2026) Presc Ins 33(7): 8

VIII. References

  1. Trobe (2012) Physicians Guide to Eye Care, AAO, San Francisco, p. 146-7

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