Exploring the Experience of Living With and Managing Presbyopia

Temporal impacts of diverse concentrations of pilocarpine ophthalmic solution on human accommodation

CLINICAL RELEVANCE

Accommodation is crucial for clear near vision and is predominantly affected by presbyopia. The ability to modulate accommodative function with eye drops could offer a pharmacological approach to manage presbyopia.

BACKGROUND

To investigate the effects of different concentrations of pilocarpine eye drops on ocular accommodation in young volunteers.

METHODS

In this prospective study, healthy volunteers with mild or moderate myopia with corrected visual acuity of no less than 20/20 were recruited. Participants underwent four visits for baselining and administration of low (0.75%), medium (1.00%), and high (1.25%) concentrations of pilocarpine eye drops respectively. One eye of each participant was chosen and analysed. Ophthalmologic examinations included objective and subjective refraction, corrected distance visual acuity, intraocular pressure, and pupil size. Accommodation was assessed using the WAM-5500 binocular autorefractor. Accommodation facility and the defocus curve were measured.

RESULTS

Volunteers (n = 24, mean age 23.7 ± 1.5 years) with a mean spherical equivalent of -2.91 ± 1.54 dioptres (D) were recruited. No serious adverse events occurred. All pilocarpine concentrations showed similar pupil constriction without significant intraocular pressure changes (p > 0.05). Pilocarpine induced greater objective refraction changes with higher concentrations (-1.12 ± 1.07D, -1.56 ± 1.38D, -1.68 ± 1.60D for low, medium, and high concentrations, respectively; p < 0.01). Subjective refraction showed a similar dose-response. Accommodative response decreased significantly at the 20 cm stimulus for medium and high concentrations (p < 0.05). Corrected distance visual acuity improved beyond -1.00D to + 0.50D defocus after all three pilocarpines. Accommodative facility improved more by 1.25% than 0.75% (p = 0.04).

CONCLUSIONS

Pilocarpine eye drops are effective in improving ocular accommodation, with higher concentrations leading to greater accommodative changes. Pilocarpine has potential for managing presbyopia.

Combination Low-Dose Pilocarpine/Diclofenac Sodium and Pilocarpine Alone for Presbyopia: Results of a Randomized Phase 2b Clinical Trial

Purpose

To evaluate the efficacy of 0.2% and 0.4% pilocarpine HCl (CSF-1) for the treatment of presbyopia and to determine the contributions of pilocarpine HCl and diclofenac sodium on the efficacy of fixed-dose combination (FDC) formulations.

Patients and Methods

This was a Phase 2b, multicenter, randomized, double-masked, parallel-group clinical trial. Adults (45-64 years) with presbyopia were randomized 1:1:1 to 3 arms (Pilo arm: pilocarpine HCl; Pilo-Diclo FDC arm: pilocarpine HCl with 0.006% diclofenac sodium; Control arm: 0.006% diclofenac sodium). Participants in Pilo and Pilo-Diclo FDC arms received 0.2% pilocarpine HCl (0.2% Pilo or 0.2% Pilo FDC, respectively) from days 1-8, and 0.4% pilocarpine HCl (CSF-1 or CSF-1-FDC, respectively) from days 8-15. Primary efficacy endpoint was achievement of ≥3-line (15-letter) gain in mesopic, monocular distance-corrected near visual acuity (DCNVA) at 40 cm, 1 hour post-treatment of the study eye on days 8 and 15 in the per protocol (PP) population. Safety endpoints were assessed.

Results

One hundred and sixty-six participants were randomized (intent-to-treat, N = 166; PP, n = 160). There were no statistical differences between 0.2% Pilo or 0.2% Pilo FDC versus Control at 1 hour post-treatment on day 8. On day 15, 43.1% and 46.9% of participants receiving CSF-1-FDC (0.4% Pilo FDC) or CSF-1 (0.4% Pilo), respectively, achieved ≥3-line gain at 1 hour post-treatment in mesopic DCNVA compared with 16.1% of Control group in the PP population, meeting the primary endpoint (P = 0.0015 and P = 0.0002, respectively). All formulations were well tolerated.

Conclusion

CSF-1 demonstrated significant improvements in mesopic DCNVA and favorable safety. Pilocarpine HCl as a single active ingredient, at the concentration of 0.4% (CSF-1), provided a transient, therapeutic effect for presbyopia.

BCLA CLEAR Presbyopia: Epidemiology and impact

The global all-ages prevalence of epidemiologically-measured 'functional' presbyopia was estimated at 24.9% in 2015, affecting 1.8 billion people. This prevalence was projected to stabilise at 24.1% in 2030 due to increasing myopia, but to affect more people (2.1 billion) due to population dynamics. Factors affecting the prevalence of presbyopia include age, geographic location, urban versus rural location, sex, and, to a lesser extent, socioeconomic status, literacy and education, health literacy and inequality. Risk factors for early onset of presbyopia included environmental factors, nutrition, near demands, refractive error, accommodative dysfunction, medications, certain health conditions and sleep. Presbyopia was found to impact on quality-of-life, in particular quality of vision, labour force participation, work productivity and financial burden, mental health, social wellbeing and physical health. Current understanding makes it clear that presbyopia is a very common age-related condition that has significant impacts on both patient-reported outcome measures and economics. However, there are complexities in defining presbyopia for epidemiological and impact studies. Standardisation of definitions will assist future synthesis, pattern analysis and sense-making between studies.

Pharmacological treatments for the correction of presbyopia

Presbyopia affects between 1.7 and 2 billion people worldwide. Presbyopia significantly impacts productivity and quality of life in both developed and developing countries. During accommodation, the human eye changes its dioptric power by altering the shape of the lens, but the exact nature of this change has not been fully explained. Recently, topical treatments have been marketed for the treatment of presbyopia and others are under investigation. In order to prepare a review of these novel therapies, we searched the major biomedical search engines. We found 15 randomized clinical trials and 12 reviews that met our review criteria. There are two different strategies for this purpose, the pinhole effect that increases depth of focus and "crystalline lens relaxation" for which parasympathetic mimetics and lens oxidation intermediates have been used. The results are generally favorable in terms of improvement of near visual acuity, although the follow-up period of the studies is short. These are novel strategies in the early stages of research that could be useful in the treatment of presbyopia.

Understanding Perspectives on Presbyopia and Use of Pilocarpine HCl 1.25% Twice Daily from Participants of the Phase 3 VIRGO Study

INTRODUCTION

The phase 3, randomized, vehicle-controlled, 14-day VIRGO study evaluated the efficacy and safety of twice-daily dosing of pilocarpine hydrochloride ophthalmic solution 1.25% (Pilo) in presbyopia. On VIRGO exit, a companion study was conducted to assess the patient experience with presbyopia and satisfaction with Pilo.

METHODS

Recruited individuals completed the Presbyopia Patient Satisfaction Questionnaire (PPSQ) plus a three-part exit survey, or a live interview. The PPSQ evaluated respondents' experience with Pilo. Survey parts 1 and 2 evaluated experience managing presbyopia before and during VIRGO, respectively; part 3 assessed future possibilities of using Pilo in real-world situations. The interview further informed the interviewees' experience with presbyopia and Pilo. The primary endpoint was responders (%) in each rating category of the PPSQ items 1-7; the secondary endpoints were summary of categorical (survey) and qualitative (interviews) responses.

RESULTS

The PPSQ and survey included 62 participants who received Pilo (N = 28) or vehicle (N = 34) in VIRGO; the interview included ten participants (Pilo, N = 4; vehicle, N = 6). Per the PPSQ, 64.3% of Pilo users reported vision improvement, including 17.9% with complete improvement; ≥ 46.4% were satisfied/very satisfied with their ability to perform daily activities, see up close unaided, and read in dim light. Among vehicle users, these percentages were 35.3%, 0%, and ≤ 23.5%, respectively. In both subgroups, ≥ 67.9% were interested in using Pilo or Pilo and eyeglasses/contact lenses in the future. Per the interview, vehicle users (n = 6/6) found the eyedrop easy to use but none experienced meaningful near-vision improvements, stopped using other correction method(s) part of the day, were satisfied with the eyedrop, preferred it over their previous correction method(s), or would continue using it if prescribed. Conversely, 75% (n = 3/4) of Pilo users responded positively to each of these six criteria.

CONCLUSIONS

Findings validate the VIRGO results and improve our understanding of the patient experience, demonstrating improved vision and satisfaction with Pilo (vs. vehicle) when performing daily activities.

Safety and Efficacy of Twice-Daily Pilocarpine HCl in Presbyopia: The Virgo Phase 3, Randomized, Double-Masked, Controlled Study

PURPOSE

To evaluate the safety, efficacy, and pharmacokinetics of pilocarpine hydrochloride 1.25% (Pilo hereafter) compared with vehicle when administered bilaterally, twice daily (6 hours apart) for 14 days in participants with presbyopia.

DESIGN

Phase 3, randomized (1:1), controlled, double-masked, multicenter study.

METHODS

Participants (40-55 years of age) had objective and subjective evidence of presbyopia affecting daily activities with mesopic, high-contrast, binocular distance-corrected near visual acuity (DCNVA) of 20/40 to 20/100. The primary/key secondary endpoint was the proportion of participants gaining ≥3 lines in mesopic/photopic, high-contrast, binocular DCNVA on day 14 (last study visit), hour 9 (3 hours after the second dose), with no more than a 5-letter loss in mesopic/photopic corrected distance visual acuity with the same refractive correction. Key safety measures included treatment-emergent adverse events (TEAEs) and some ocular measurements. Pilocarpine plasma levels were assessed in approximately 10% of enrolled participants.

RESULTS

Overall, 230 participants were randomized to Pilo twice daily (N = 114) and vehicle (N = 116). The proportion of participants achieving the primary and key secondary efficacy endpoints was statistically significantly greater with Pilo twice daily than vehicle, with between-treatment differences of 27.3% (95% CI = 17.3, 37.4) and 26.4% (95% CI = 16.8, 36.0), respectively. The most common TEAE was headache, reported in 10 participants (8.8%, Pilo group) and 4 participants (3.4%, vehicle group). Pilocarpine's accumulation index on day 14 was ≤1.11 after the second dose.

CONCLUSIONS

Near-vision improvements were statistically greater with Pilo twice daily than with vehicle, without compromising distance acuity. The safety profile of Pilo twice daily was consistent with that of Pilo once daily, and systemic accumulation was minimal, supporting twice daily administration.