Hello everyone, this is Dr. Audrey Tai. I am a board certified and fellowship trained
refractive and cataract surgeon, ophthalmologist and cornea specialist, welcome back to my
channel - Eye channel by eye surgeon. In today's video I will review the treatment
options for presbyopia AKA the need for reading glasses that starts for many people in their
early 40s. I will go over the cause of presbyopia, the
latest FDA approved Vuity eye drop, as well as Surgical treatment options that are currently
available in the US. If you don’t have time to watch 10 minute
videos, you can follow me on Instagram @draudreytai for short fun videos to learn more tips to
care for your eyes. So what is presbyopia? Presbyopia is the decrease
in close up reading vision that occurs in our eyes as we age.
As you age, you may start to notice that reading small or fine print becomes more and more
difficult over time, and you may find yourself holding your reading material further and
further away. Eventually you may need over the counter reading glasses, prescription
bifocal glasses, or multifocal contact lenses in order to be able to read small print. If
you are affected by presbyopia, you are not alone. Presbyopia affects 128 million Americans,
and the number continues to grow. So what causes presbyopia? The lens in our
eye is flexible and is designed to change shape when muscles in our eye called the ciliary
body contract. It is this ability of the lens to change shape that enables us to see objects
clearly at different distances, by changing the focus. When the lens shape is more curved,
the eye becomes more nearsighted, thus enabling us to clearly see objects that are close to
us. The reverse happens when we look at objects further away.
As we age, our lenses gradually lose their flexibility, and no longer change shape when
our eye muscles contract, causing presbyopia.
Although currently there's no available treatment to restore the elasticity of our natural lens,
there are several effective presbyopia treatments to get around this limitation. I have no financial
interest in any of the treatments that I mention in this video, all of the treatment options
I review for you in this video are based on my own clinical experience and study.
Recently, a lot of my patients have been asking about the newly FDA approved Vuity eye drop
made by Allergan. Vuity is a prescription eye drop that contains 1.25% pilocarpine as
its active ingredient. Pilocarpine temporarily improves near vision through two mechanisms.
First off, if your lenses still have any residual elasticity, Pilocarpine will stimulate contraction
of the ciliary body muscle to shift your eyes into a more nearsighted state as I mentioned
earlier, temporarily improving near vision. The second, and main way that Vuity affects
near vision is by stimulating the parasympathetic muscles in the iris to constrict the pupil
which creates a pinhole effect. You have likely experienced the pinhole effect yourself when
you go to your eye doctor's office and have your vision checked with one of these. This
is called an occluder. You may have noticed that when you look through one of the small
holes with the flap down, you see more clearly. This phenomenon is called the pinhole effect.
Pilocarpine constricts the pupil size causing a pinhole effect.
Pilocarpine was initially approved by the FDA in 1974 to treat glaucoma, or to constrict
the pupil when needed for eye exams or eye surgeries.
Vuity contains 1.25% pilocarpine, and was recently approved by the FDA in October 2021
for the treatment of presbyopia. It is dosed at one drop in each eye once a day. According
to clinical trial data from the GEMINI 1 and 2 studies, the effect of near vision improvement
from Vuity can be seen as early as 15 minutes after applying the eye drop, and can last
up to 6 to 10 hours. However there are some potential side effects
of Vuity, in the GEMINI 1 and 2 studies, patients reported eye redness and headaches. Using
Vuity may also decrease night vision by reducing the amount of light entering your eyes at
night through a small constricted pupil. So you may need to be careful when using it at
night. Pilocarpine can also rarely cause retinal Detachment. So it is important to consult
with your eye doctor if you are considering using Vuity. At the current time, Vuity is
not covered by most insurance, and costs about $75 for each 2.5 ml bottle. As Vuity is newly
approved for presbyopia, we’ll likely learn more and more about this medication as it
becomes more widely available in the US. Let me know in the comments below if you would
like me to post a video in the future to review my clinical experience with Vuity in my practice.
And don’t forget to subscribe to my channel, so you won’t miss any of my new videos.
One option for long term presbyopia treatment is LASIK surgery. A lot of us are familiar
with LASIK as a treatment for nearsightedness. But did you know that LASIK can also be used
to treat presbyopia? For my LASIK patients with presbyopia, I plan two different customized
treatments, one for each eye. This means that each eye sees a little differently, with one
eye slightly more nearsighted than the other, while the other eye sees distant objects more
clearly. This technique allows the patient to see both distant and near objects clearly
when both eyes are open. Having slightly differently corrected vision in each eye is called monovision.
You may have heard of or even wear contact lenses for monovision yourself. Having LASIK
surgery to create monovision is like having the prescription correction from contact lenses
permanently on your eyes. I perform femtosecond laser wavefront guided all laser LASIK surgery,
using two different lasers. During the surgery, the first laser, the femtosecond laser, will
create a very thin flap on the cornea, then the flap is lifted, and the second laser,
the excimer laser reshapes the cornea to the targeted prescription to create monovision.
A possible limitation of monovision is slightly decreased depth perception because one eye
is more nearsighted than the other. The exact amount of difference between the two eyes
for monovision needs to be carefully chosen by you and your eye surgeon, and this is not
always as simple as it sounds. It is important to balance depth perception, distance vision
and near vision to obtain the best visual outcome that is possible for your eyes. In
my practice, I have every patient who is considering monovision LASIK surgery for presbyopia wear
contact lenses for a time, to simulate the visual outcome of monovision, and we only
proceed with the surgery if they like the simulated vision. To learn more about the
different risks and benefits of contact lenses and LASIK, you can check out this video – contact
lens vs LASIK, which one is safer? There is a permanent treatment option for
presbyopia available by your eye surgeon called refractive lens exchange. It is essentially
the same surgery as cataract surgery for cataract removal. Replacing the crystalline lens not
only treats cataracts, but can also treat presbyopia by removing the old stiff lens,
and replacing it with an advanced multifocal or extended depth of focus intraocular lens
implant or IOL. These special implantable lenses bend the light rays entering our eyes
at different focal points, enabling us to have clear distance vision for objects that
are far away, clear intermediate vision such as using a laptop, and clear near vision for
reading cellphones or books. I perform femtosecond laser assisted refractive lens exchange surgery
for my presbyopic patients. To learn about the differences between laser assisted cataract
surgery and conventional manual cataract surgery, you can check out this video.
Both monovision LASIK surgery and refractive lens exchange surgery are surgical options.
There are potential risks associated with any surgical procedure. So be sure to have
an individualized eye exam and consultation with your eye surgeon to find which treatment
option is the best one for you. Let me know in the comments below if you need
reading glasses now, and if so, which treatment option I mention in this video interests you
the most as an alternative to reading glasses. All of the treatment options I mentioned in
this video are currently available in the US. There are other treatments available internationally,
such as different types of cornea inlays, and laser cornea surgery.
I hope you find this video helpful, if you have learned anything new, please don’t
forget to hit the Like bottom, and subscribe to my channel, to help me bring you more videos
about eye health and eye surgery. You can also follow me on Instagram, Facebook
and LinkedIn at Dr. Audrey Tai to learn more about my practice. I look forward to connecting
with you there. Thank you again for watching and I will see
you in my next video.
while when we're trying to see objects that are far away from us, the ciliary body muscles
relax, the zonular fibers then tighten up and stretch the lens to make it less curved.
Presbyopia is due to loss of flexibility or elasticity of the natural crystalline lens
in our eyes. the natural crystalline lens inside of our eye is flexible and can change
its focus by changing its shape when we are young.
This ability of the lens to change shape is called accommodation. The way it works is
there are lots of tiny fibers connecting the lens to the circular muscle inside of our
eyes called the ciliary body. Those tiny fibers are called zonular fibers. When the ciliary
body muscles contract, the zonular fibers relax, the lens becomes more curved, and the
eye becomes more nearsighted, thus enabling us to see objects that are close to our eyes;
the opposite occurs when we try to see objects that are far away. therefore our eyes gradually
require assistance from reading glasses to provide additional power to form clear images
of objects close to our eyes. The pinhole effect Increase the depth of focus
of our eyes, in order to improve near Vision in people who have presbyopia. Secondly, pilocarpine
can stimulate contraction of the ciliary muscle to shift the eyes into a more nearsighted
state as I mentioned earlier, to improve near vision.
According its manufacture Allergan, vuity uses a proprietary pHast technology to adjust
the pH of the eye drop to be close to our physiological pH, in order to reduce the common
side effect such as stinging and eye redness that can occur when using Vuity.
Let me know in the comments below, if you have tried Vuity eye drop and what your experience
has been. Nearsightedness means the eye is too long
and light rays focuses in front of the retina, so without correction, objects that are far
away seems blurry, but the near ones are clear. However, because our eyes can naturally accommodate
a small amount of difference between the two eyes, most of the time, your eyes can adjust
to small amount of monovision just fine, so if the difference between the two eyes is
within the limit of what our eyes can tolerate, a lot of people can adjust to monovision,
but not everyone. The aging change occurs in the crystalline
lens inside our eyes are staged and gradual, starting from loss of accommodation or elasticity
of the lens, to gradually becoming cloudy to form cataracts.
The same surgery for removing cataracts, which is a cloudy crystalline lens, can also treat
presbyopia. In the past, we only perform cataract surgery when the crystalline lens forms a
dense cataract, but now we can perform the same procedure to remove the crystalline lens
prior to cataracts formation, thanks to the advanced intraocular lens technology.
if you stay with me until the end of this video, I will also review a few lesser-known
treatment options. Thank you for staying with me until the end
of this video. As I mentioned at the beginning of this video, I will also review a few lesser
known treatment options for presbyopia. One is conductive keratoplasty. It is a surgical
procedure to imprint few rolls of circular burn marks on the cornea to make the eye more
nearsighted, similar intention as monovision LASIK surgery. I personally do not perform
conductive keratoplasty, as the effect of the cornea curvature change from this procedure
is typically not long lasting. The other treatment option available is cornea inlay surgery,
by implanting a small circular ring inside of the cornea tissue to create a pinhole effect
to improve near vision. This procedure typically require significant adaptation and vision
training post operatively, I personally do not perform it.