Other Autonomic Agents for the Treatment of Presbyopia & Ptosis - Clinical Ocular Pharmacology Spring 2026

NO, that is not the mechanism by which presbyopia occurs. They do not lose their ability to accommodate. They lose the elasticity in the lens. The lens is not affected by ciliary body accommodation in presbyopia.

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

Vuity

What is the first FDA approved drop for the tx of presbyopia?

1.25% pilocarpine

What is the drug formulation of Vuity drop?

for the treatment of presbyopia

What is Vuity approved by?

a parasympathomimetic, cholinergic agonist that binds to muscarinic receptors on the iris sphincter

What is the MOA of Vuity?

yes -- there are muscarinic receptors in the ciliary body. BUT, this is not the mechanism of action of the drug

Does Vuity bind to the ciliary body?

Causes pupillary miosis that increases the depth of focus to improve visual acuity

What is the therapeutic effect of Vuity?

1 gtt BID OU

What is the dosage of Vuity?

-Patients had to have 3 lines of near acuity improvement and NO loss of distance visual acuity

-40% passed this metric

What were the metrics for the approval of Vuity as a presbyopic drop by the FDA? How many people passed this metric?

Decreased IOP by enhancing TM outflow (2-4% dosage for glaucoma tx)

What is another therapeutic effect of Vuity besides improving the depth of focus at near?

-browache/headache

-accommodation inducing distance blur

-conjunctival injection

-retinal detachment (CB and choroid contracting/tension on peripheral retina)

What are the reported SEs of Vuity?

Exercise caution with night driving

What is a precaution for Vuity use?

-bradycardia

-bronchoconstriction

-sweating

-salivation

-abdominal cramping

What are the possible parasympathomimetic SEs of topical ophthalmic pilocarpine (Vuity)?

-<50

-ADD <2.00

-Emmetropic presbyopes

-Single vision CL wearers

-Multifocal CL dropouts/nonadapts

-Can be used in addition to multifocal CLs

Who is an IDEAL candidate for Vuity?

DFE

What needs to occur BEFORE Vuity use to rule out any existing peripheral retinal disease?

-Supplied in 2.5mL bottle (1 month)

-No insurance coverage

-$91 for local pharmacy

-$79 for E-rx to UpScript to direct ship to patient

What is the Cost & Supply of Vuity?

0.4% pilocarpine (PF)

What is the drug formulation of Qlosi drop?

for the treatment of presbyopia

What is Qlosi FDA approved for?

A parasympathomimetic, cholinergic agonist that binds to muscarinic receptors on the iris sphincter

What is the mechanism of action of Qlosi?

causes pupillary miosis that increases the depth of focus to improve near VA

What is the therapeutic effect of Qlosi?

1 gtt BID OU

What is the dosage of Qlosi?

-Similar efficacy to Vuity

-40% of patients improves 3 lines near VA without losing distance VA

-80% achieve 20/40 or better near VA

Qlosi efficacy?

-HA

-Sting on instillation

What are the SEs of Qlosi?

-$79/month

-through BlinkRx online pharmacy

What is the cost/supply of Qlosi?

1.44$ aceclidine (PF)

What is the drug formulation of Vizz drop?

for the tx of presbyopia

What is Vizz approved for?

A parasympathomimetic, cholinergic agonist that SELECTIVELY binds iris sphincter muscarinic receptors

What is the MOA of Vizz?

causes pupillary miosis that increases the depth of focus and near VA

What is the therapeutic effect of Vizz?

2 gtt QD OU

What is the dosage of Vizz?

-$79 for 1 mo supply

-Through UpScript online pharmacy

What is the cost/supply of Vizz?

highest

Vizz has the ______ efficacy of FDA presbyopic agents

73%, 90%

_____% of patients improve 3 lines of near VA without losing more than 1 line of distance VA with Vizz. ____% achieve 20/40 near VA

-instillation irritation

-dim vision

-HA

-conj injection

What are the SEs of Vizz?

exercise caution with night driving

What are the precautions of Vizz use?

0.1% oxymetazoline hydrochloride

What is the drug formulation of Upneeq drop?

approved for acquired blepharoptosis

What is Upneeq used for?

Non-selective alpha adrenergic agonist that contracts Mueller's muscle

What is the MOA of Upneeq?

increases the palpebral fissure by at least 1 mm

What is the therapeutic effect of Upneeq?

-punctate keratitis

-instillation irritation

-conj hyperemia

-blurred vision

-HA

-dry eye

-sympathomimetic SEs (increased BP)

-angle closure glaucoma

What are SEs of Upneeq?

patients with narrow angles should avoid

What are the precautions of Upneeq use?

Upneeq Results (PIC)

Upneeq Results (PIC)

Measure the Margin Reflex Distance (MRD1) to assess the degree of ptosis in a patient

How to Assess to Degree of Ptosis & Demonstrating Upneeq Effect to Patients

What is the first step?

mm from corneal light reflex to the center of the upper eyelid margin in primary gaze. Normal = 4-5mm. Asymmetric = >1mm difference

How to Assess to Degree of Ptosis & Demonstrating Upneeq Effect to Patients

How do you measure the MRD1? What is a normal value?

Confirm dx of BENIGN acquired blepharoptosis

How to Assess to Degree of Ptosis & Demonstrating Upneeq Effect to Patients

After measuring MRD1, what is the next step?

RULE OUT Horner's, Myasthenia Gravis, Oculomotor nerve palsy, Chronic progressive external ophthalmoplegia

How to Assess to Degree of Ptosis & Demonstrating Upneeq Effect to Patients

How to confirm dx of BENIGN acquired blepharoptosis?

Demonstrate Upneeq

How to Assess to Degree of Ptosis & Demonstrating Upneeq Effect to Patients

After confirming dx of BENIGN acquired blepharoptosis, what is the next step?

Use pt's phone to take baseline pic, Instill 1 gtt of Upneeq, Wait 20 min, Retake photo and document change in the MRD1

How to Assess to Degree of Ptosis & Demonstrating Upneeq Effect to Patients

How to demonstrate Upneeq?

-30 single use PF vials = $105

-90 single use PF vials = $255

-No insurance coverage

-Only available through RVL mail order pharmacy

How is Upneeq Supplied and what is the cost?