REFRACTIVE EWAP SEPTEMBER 2022 43 reading glasses. Pilocarpine formulation The Vuity drop uses pilocarpine that has been specifically formulated for the treatment of presbyopia. “Pilocarpine has been around for more than 100 years, so it’s a well - known ophthalmic therapeutic,” Dr. Waring said. The concentration was carefully studied, as was the proprietary vehicle with the pHast technology, which he said made a difference in the efficacy and tolerability. “Relative to historic formulations of pilocarpine, the pHast technology allows the molecules to rapidly equilibrate to the natural pH of the eye, reducing side effects and increasing the onset of action and efficacy, thereby being able to use a lower concentration and keeping a favorable side effect profile but still achieving efficacy,” Dr. Waring said. Dr. Chu said that Vuity has a dual mechanism of action. It’s 1.25% pilocarpine, he said, adding that it works by contracting the ciliary muscle and constricting the pupil. For most patients, it’s that pupillary constriction, the reduction in aperture size of the pupil, that increases the depth of focus. “I think it’s important to understand that it has the dual mechanism because using the classification system, we found that if you use it in early presbyopes, people just turning 40 are noticing slight changes in focusing ability, and Vuity could cause myopia and affect distance in those patients,” Dr. Chu said. “But if you use it in the older patient population, whose focusing ability has been compromised by age, they don’t have that side effect of the myopia induction from ciliary body constriction, so it’s just the aperture effect.” Dr. Chu said some may suggest it’s not really new because it’s pilocarpine. But he thinks the pharmacology of Vuity is different. Pilocarpine has to be stored acidic, which burns the eye. “I think it’s important to note that Allergan created the pHast technology, a buffered solution, to make it comfortable,” Dr. Chu said. “It’s stored acidic, but as soon as it hits the eye, it reaches physiologic pH to minimize burning and improve bioavailability.” Early opinions Vuity is first in class, and there is an exciting future for this class, Dr. Chu said, adding that it’s not for every patient and it’s important to set expectations. He has found the biggest pushback is some patients might not notice reading for as long. Dr. Chu said there have not been serious complications. Adverse reactions like headaches, blurriness, or redness have tended to be mild and generally improve after a few days of use. Dr. Chu recommended that patients give the drops a week if they have any issues adapting. They may also try different lighting situations to determine what works best. Dr. Waring has found Vuity to fill a niche in the refractive space for the earlier presbyope. “Vuity has been a wonderful addition to the pipeline of treatment,” he said. “As their presbyopia becomes more manifest and the lens becomes increasingly dysfunctional, we introduce the concept of lens replacement early on as the next step.” For those who are either more hyperopic or have more manifest presbyopia in stage 1–2 lens dysfunction, he will talk more about custom lens replacement as the most appropriate solution for them, he said. Concerns/ contraindications Dr. Waring noted that he will discuss with and document certain categories of patients who might be at a higher risk for other conditions. For example, in high axial myopes who have an increased risk for retinal detachment, he may consider other forms of vision correction such as implantable contact lenses or LASIK, as well as those patients with narrow angles, higher hyperopes, and shorter eyes. “For these types of patients, we might be thinking more about lens replacement,” he said. Dr. Chu is also careful with high myopes. He stressed the importance of a recent full retinal exam. While the risk for retinal detachment is low, Dr. Chu takes a conservative approach in patients with a high degree of myopia. Other thoughts Dr. Waring said that it’s exciting to be able to incorporate Vuity into practice, especially since it’s a first-in-class product and was approved earlier than anticipated by the FDA. However, he stressed that the FDA clinical trials were short term, so it will be important to look at long-term data to see that it continues to support the safety and efficacy. He added that there has also been some success with alternative off-label indications, such as dysphotopsia and improvement in distance and reading vision with various diffractive and monofocal IOLs. “That’s been a wonderful addition to our armamentarium,” he said, adding that this is worth further evaluation and exploration. Dr. Chu said that “it’s exciting to see how it evolves in the marketplace.” He thinks the success of Vuity will be driven by consumers and their interest. “As eyecare providers, I think we need to educate ourselves and embrace this new option for our presbyopic patients.” EWAP Editors’ note: Dr. Chu is in practice at Chu Vision Institute, Bloomington, Minnesota. Dr. Waring is in practice at Waring Vision Institute, Mt. Pleasant, South Carolina. Both have interests with Allergan.
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