Presbyopia Drops: Worth the Hype?

Miotic eye drops have joined the list of available options for presbyopia treatment. However, they have not yet reached their full potential, and there is still a long way to go in deciding where they fit in. Giovanna Benozzi MD and Sotiria Palioura PhD discussed the pros and cons at a recent conference.

A universal human experience, presbyopia is expected to affect an estimated 2 billion people by 2030. The skyrocketing numbers are due to a longer life expectancy and more near-vision activities.

“Eighty per cent of these people feel disabled by the reduced near vision, not only in the work environment but also for their daily activities,” Dr Benozzi said.

Presbyopia has a high impact on productivity, with effects on working-age patients younger than 50 years old costing $11 billion annually, which increases to $25 billion for those younger than 65 years old, she added. The responsibility on the shoulders of ophthalmologists and researchers is therefore significant.

Currently, the treatments offered to patients for presbyopia are glasses, contact lenses, and lenticular and refractive laser surgical solutions.

“All these have trade-offs, especially for early presbyopes in their 40s and 50s and patients demanding reversible non-surgical options,” Professor Palioura commented.

Presbyopia eye drops gained popularity in research following the assumptions of the most widely accepted theory on accommodation from Hermann von Helmholtz, among others, which focused on two concepts: miotic drops and lens softening drops.

Miotic drops use parasympathetic agents to induce miosis and a pinhole effect by pupillary constriction, avoiding ciliary muscle contraction and increasing the depth of focus, potentially stimulating limited accommodation in early presbyopia. Unlike pilocarpine, aceclidine selectively targets the iris sphincter only, without stimulating the ciliary muscle.

Lens softening drops, in contrast, try to trick the root cause of the problem of presbyopia by breaking disulfide bonds, decreasing lens stiffness, and increasing true accommodation. However, conceptually attractive lens softening drops failed phase 2 clinical trials in 2022, Prof Palioura noted.

Only miotic drops have obtained US FDA approval, with pilocarpine 1.25% and 0.4% approved respectively in 2021 and 2023, aceclidine in the summer of 2025, and the combination carbachol-brimonidine in January 2026.

Clinical trials on these molecules showed positive results.¹ Of the presbyopic patients receiving pilocarpine 1.25% once a day, 30% gained three lines of near vision at three hours, with an onset of 15–30 minutes and a duration of six hours. Nearly half of the patients receiving pilocarpine 0.4% twice a day gained three lines at one-hour post-dose, with an onset of 20 minutes and a duration of eight hours. Two-thirds of patients receiving aceclidine once daily gained three lines at three hours, with an onset of 30 minutes and duration of 10 hours.²

The combination carbachol-brimonidine once daily produced gains of three lines in 40% of patients at one to two hours, with an onset of 30 minutes and duration of 10 hours.³ Subgroup data for pseudophakic patients are not yet published. In all trials, distance vision was preserved under photopic conditions.

Reading the fine print

However, real-world data suggests that while patients report improved near vision for tasks such as reading phones, such benefits do not extend to prolonged reading activities. Early to moderate presbyopes (+1.00 D to +1.50 D) appear to do best. Side effects include head and brow ache, transient blur, dim vision, and some instillation discomfort with associated conjunctival hyperaemia.

Moreover, there are some safety concerns about the risk of retinal detachment with a higher concentration of pilocarpine, especially in high myopes and patients with lattice degeneration, as a small pupil reduces light intake.

Dr Benozzi and her group have worked the last 18 years on a combination of pilocarpine and the anti-inflammatory diclofenac, which modulated both miosis and ciliary vessel response, reducing side effects like inflammation while maintaining vision at all distances. Long-term follow-up showed no synechiae, no retinal detachment, and strong patient adherence.

Presbyopia drops are a viable option under physician supervision, especially for chronic usage, Dr Benozzi said.

“The professional evaluation of these drops is very important—the selection of patients, the evaluation of their ocular conditions, and the risk factors and the degree and progression of presbyopia, especially with a combination of parasympathetic agents and anti-inflammatory,” she added. “We may offer an option for patients who are not surgical candidates yet or prefer to avoid surgery.”

However, they are not yet a game changer.

“There was a lot of hype in the beginning, but expectations were too high and they outpaced the results,” Prof Palioura said. “But there is hope and a meaningful benefit for selected patients with honest counselling. It is a rapidly evolving field.”

Prof Palioura and Dr Benozzi spoke at the 2026 ESCRS Winter Meeting in Helsinki.

Sotiria Palioura MSc, PhD, CEBT, FEBO, FEBOS-CR is Professor of Clinical Ophthalmology at the Bascom Palmer Eye Institute, University of Miami, US. sotiria.palioura@gmail.com

Giovanna Benozzi MD is Founder and Member of the Presbyopia Argentine Society and Director of the Presbyopia Advance Research Centre in Buenos Aires, Argentina.

1. Singh M. Curr Ophthalmol, 2025 Jan 18; 36(2): 111–121.

2. Grzybowski A. Adv Ophthalmol Pract Res, 2024 Sept 3; 4(4): 220–225.

3. “Safety and Efficacy Study of BRIMOCHOL™ PF and Carbachol PF in Subjects with Emmetropic Phakic and Pseudophakic Presbyopia.” Clinicaltrials.gov. 2026. https://clinicaltrials.gov/study/NCT05135286