Autonomic Agents

Would a drug that enhanced ciliary body muscle contraction improve accommodation for presbyopes?

No

Vuity

• 1.25% pilocarpine

• FDA approved for the treatment of presbyopia

• Mechanism of action: parasympathomimetic/cholinergic agonist that binds muscarinic receptors on the sphincter

• Therapeutic effect: Causes pupillary miosis that increases the depth of focus to improve near visual acuity

• Dosage: 1 gt BID OU

• Can also dec. IOP via inc TM outflow

• Reported ocular side effects:

  • 15% Browache/headache

  • 5% Accommodation inducing distance blur

  • 5% Conjunctival injection

  • Retinal detachment

  • Precautions: exercise caution with night driving

• Potential Parasympathomimetic Systemic Side Effects:

  • bradycardia

  • bronchoconstriction

  • sweating, salivation

  • Abdominal cramping

• Ideal Candidates:

  • Age ≤ 50

  • ADD ≤ 2.00 D

  • Emmetropic presbyopes

  • Single vision CL wearers

  • Multifocal CL dropouts/nonadapts

  • Can also be used in addition to multifocal CLs

  • No peripheral retinal disease (do DFE)

• Supplied in 2.5ml bottle (1 month supply)

• NO INSURANCE COVERAGE

Qlosi

• 0.4% pilocarpine (preservative free)

• FDA approved for the treatment of presbyopia

• Mechanism of action: A parasympathomimetic, cholinergic agonist that binds muscarinic receptors on the iris sphincter

• Therapeutic effect: Causes pupillary miosis that increases the depth of focus to improve near VA

• Dosage: 1 gt up to BID OU

• Similar efficacy to Vuity

• Side effects:

  • Headache 6.8%

  • Sting on instillation 5.8%

  • no retinal detachment risk

VIZZ

• 1.44% aceclidine (preservative free)

  • Muscarinic agonist, but more so for M3 on iris

• FDA approved for the treatment of presbyopia

• Mechanism of action: A parasympathomimetic, cholinergic agonist that SELECTIVELY binds iris sphincter muscarinic receptors

• Therapeutic effect: Causes pupillary miosis that increases the depth of focus to improve near VA

• Dosage: 2 gt QD OU

• Highest efficacy of FDA presbyopia agents

• Ocular Side Effects:

  • 20% Instillation irritation

  • 16% Dim vision

  • 13% Headache

  • 8% Conjunctival injection

  • Precautions: exercise caution with night driving

Upneeq

• 0.1% oxymetazoline hydrochloride

• FDA approved for acquired blepharoptosis

• Mechanism of action: Non-selective alpha adrenergic agonist that contracts Müller’s muscle

• Therapeutic effect: Increases palpebral fissure by at least 1mm

• Side effects in 1-5% of patients:

  • Punctate keratitis

  • Instillation irritation, conjunctival hyperemia

  • Blurred vision, headache, dry eye

• Other potential side effects:

  • sympathomimetic side effects like increased BP

  • Angle closure glaucoma

  • Precautions: narrow angle patients

Assessing Ptosis

1. Assess degree of ptosis by measuring Margin Reflex Distance 1 (MRD1)

   1. mm from corneal light reflex to the center of the upper eyelid margin in primary gaze

      1. normal = 4-5mm

      2. A difference of ≥1mm = asymmetry

2. Confirm diagnosis of benign acquired blepharoptosis by ruling out:

   1. Horner’s syndrome

   2. Myasthenia Gravis

   3. Oculomotor nerve palsy

   4. Chronic progressive external ophthalmoplegia

3. Trial demonstration

   1. Ask to use patient’s phone to take baseline photo

   2. Instill 1 gt Upneeq OU

   3. Wait 20 minutes

   4. Retake patient photos and document change in MRD1