From readers to topical pharmaceuticals: a new dawn in presbyopia care

In an episode of The Spotlight Series Podcast, host Mario Nacinovich brings together Selina McGee, OD, of BeSpoke Vision, and Jacob Lang, OD, of Associated Eye Care, to talk about the current state of presbyopia care. Drs. McGee and Lang emphasize the frustration presbyopia creates for patients and the need for more proactive, empathetic conversations as eye care providers. They discuss the expanding treatment landscape, focusing on patient selection, expectation-setting, and real-world integration into practice.

Mario Nacinovich:

Welcome back to The Spotlight Series. I’m your host, Mario Nacinovich, and today we’re diving into one of the most universal visual complaints in eye care, presbyopia. Age-related, blurry, near vision that makes simple tasks like reading a text message or a menu unexpectedly challenging for adults over 40.

I’m thrilled to be joined by 2 great friends and leaders in optometry who are on the front lines of presbyopia care. From Edmond, Oklahoma, we have Dr. Selina McGee, an optometrist who lectures extensively on presbyopia and the evolving treatment landscape. From the land of 1,000 lakes, Minnesota, we’re joined by my good friend, Dr. Jake Lang, an optometrist with deep expertise ocular surface disease and surgical co-management. Selina and Jake, welcome to The Spotlight Series.

Selina McGee, OD:

Thanks, Mario.

Jacob Lang, OD:

Thanks, Mario.

Mario Nacinovich:

Let’s start with the big picture. Welcome to presbyopia, where is your menu in 4K, but your eyes are still in standard definition. Selina, for listeners who may just know presbyopia as, my arms aren’t long enough anymore, how do you define presbyopia in the exam room? Why is it such a disruptive diagnosis for patients in their 40s and 50s?

Selina McGee, OD:

I think it’s interesting. It is disruptive to our patients. This is the first time they experience and have a first glimpse at mortality, when their body will no longer allow them to do something. But I think what’s really interesting about this is Jake and I and all the eye care providers out there talk about and diagnose presbyopia all day, every day. There’s a little bit of a danger in that because you have to really lean into your patients and listen to what they’re saying and remind yourself that this patient is going through presbyopia for the first time and it’s a journey.

I think that I never like my patients to be surprised by anything, and so I always start this conversation in their typically mid 30s. Or if a patient’s dilated, I gently remind them, “This is what your mom and dad feel like, so maybe don’t make so much fun of them.” Right? I think that we need to humanize this a bit and expand into the conversations, because our patients don’t know what they don’t know.

Mario Nacinovich:

You’ve touched on that emotional side, and let’s start off there. What are 1 or 2 phrases that you are consistently hearing over and over that really captures how much this bothers people, especially those who perhaps even never needed glasses before?

Selina McGee, OD:

I think the word that comes to mind is frustration, they’re frustrated. With the options that we have for them, historically, my first part of my career was spectacles and then contact lenses and multifocal contact lenses made more headway. Then we had more surgical options, now we have therapeutic options. Our patients think that the only real option is still reading glasses because that’s what their parents wore, and again, they just don’t know what they don’t know. But I think the biggest piece is frustration and they think they just have to live with this, and that’s one of my biggest pet peeves. That’s why I’m so passionate about presbyopia, why I’m so passionate about dry eye, is patients reset their normal. They think it’s okay that, “Oh, I’ll just blow my phone up.” Granted, the intergalactic space station can see it because the font’s so big, but this is just how life is. It doesn’t have to be like that.

I think that’s why I’m so passionate about it and why I like to have these conversations with patients, because they’re always surprised that, oh, there are more opportunities for me to be able to help. Yes, 100% of our patients are going to get presbyopia, and yet we spend very little time talking about or thinking about it. If we had any other condition or disease state that 100% of our patients would get, I think we would spend a lot more time talking about it. I feel like this has just been overlooked for most of our careers. There’s a lot of opportunity here.

Mario Nacinovich:

Jake, building on that, how big is big? How big is it from a public health and practice standpoint? Roughly how common is presbyopia, and what does it mean for an optometry or an ophthalmology clinic today in 2026?

Jacob Lang, OD:

Right. Yeah, I think it’s the biggest opportunity eye care has as we move forward, really. It’s about, I think, Selina can confirm this, but about 130 million Americans have presbyopia, and there’s new presbyopes born every day. Right? Everyone gets that magic birthday candle where our focusing system just isn’t what it used to be.

It’s this huge. If we think about it, just putting that number into scale, if we think about 4 million Americans have glaucoma, 130, I’m no math matician here, but we’re talking 3, 4 times more patients have presbyopia than glaucoma, 30 million Americans have dry eye disease, and so we’re add a zero to that first one and another 3 to four 4. So, four times more patients have presbyopia than dry eye. You think about how big of a market ocular surface disease and dry eye is, these are really big numbers that I don’t like, to Selina’s point, we’ve for too long been complacent with saying, yeah, this is a thing and it is, and we take it for granted, but our patients are like…I was thinking, frustration’s one word. I was thinking more like WTF with this, because as I’m going through presbyopia, I’m like, you can’t see the receipt at a restaurant? How do I know what I’m paying for?

Mario Nacinovich:

I’m typically blaming the low light and low contrast sensitivity myself.

Jacob Lang, OD:

Yeah, not the birthday candles, right?

Mario Nacinovich:

Yeah, yeah.

Jacob Lang, OD:

It’s gotten to a point where it’s almost like ageism. Right? We don’t talk about it. If you were a more senior person at the office, are you going to admit that you can’t see things to your younger colleagues? No. They come to their eye doctor to talk about it, and then we blow it off too. Yeah, we see this all day, every day, this is just no big deal. Nobody’s giving these patients time to vent about this and talk about it, and I’m learning that as I enter these years and like, “What do you mean I can’t see my food?” This is a real thing. Lots of opportunity, to Selina’s point as well, but just huge numbers that I don’t think we really recognized in eyecare.

Mario Nacinovich:

A growing population, essentially universal by mid-40s. I will admit, as a 54-year-old, that I’ve been in my multifocal contact lenses for about 10 years now. Thank you, Bausch + Lomb. We’ve got a massive, often frustrated, WTF, according to Jake, patient population. Historically, our answers have been, as Selina said, readers, bifocals, these multifocal contact lenses, and there’s been some surgical options. But today, we finally have pharmacologic options on the table. Jake, let’s explore these because I’ve certainly heard in the recent past, the only thing that would get stronger every year for many patients was their reading prescription. Now, there’s actually prescription options for them.

Jacob Lang, OD:

Yes. Yeah, so we’ve entered the new era of pharmacologic agents for correcting a refractive disorder, specifically presbyopia. Right? We have the opportunity to help our patients with a pharmacologic option as opposed to just an optical option, whether that was glasses, contacts, or whatever.

Most of these drops are working with miosis. Right? I always explain it when you dilate someone’s eyes, when I’m explaining this to patients, “Hey, your eyes are dilated. Notice how much worse your up close vision is, how bad it is? These drops do the opposite. They make your pupil smaller, and by making your pupils smaller, we’re increasing your depth of field. We’re increasing your ability to do things up close.” Is this perfect? No. Is it curing? It doesn’t cure my hairline, it doesn’t cure the aches and pains in my knees, but it does help us see better. This is how it works and we’re entering this, and we need to embrace it, acknowledge it, and I think it’s a great option for a lot of patients.

Mario Nacinovich:

At a high level, for the optometry audience in the room or maybe some ophthalmologists or technicians that are listening, how do these drops work to improve near vision without completely sacrificing distance vision?

Jacob Lang, OD:

Yeah, yeah. It works on that miosis pinhole effect. We’re making the pupil smaller. We’re making that pupil smaller, we’re decreasing the amount of blur that comes through that pupil and enhancing our ability to do up close vision by increasing what we call our depth of field or our depth of vision. It’s really that pinhole effect that allows that to occur. It comes with a myriad of things, but yeah, it’s an opportunity to increase that depth of field.

Mario Nacinovich:

We’ll dig into that a lot more as well. We’re essentially using a drop to create a controlled temporarily pinhole camera effect, smaller pupil, greater depth of field, better near clarity, while aiming to keep distance vision functional for everyday tasks.

Now, Selina, as I recall, not too long ago, Vuity was the first FDA-approved presbyopia drop. What happened there? Now we’ve got Qlosi as another option. How has the arrival of these medications changed your presbyopia conversations in the clinic?

Selina McGee, OD:

Yeah, I think with the first FDA-approved Vuity, this was a new paradigm shift, as far as having a category for presbyopia beyond the traditional methods of spectacles, contact lenses, or surgical options, we have a pharmacological option. The first version of things, we always learn more and wish we had done some things differently, but you don’t know what you don’t know when you’re launching or when you’re going through 8 to 12 years of bringing a drug to market.

What we learned is with the pinhole effect, and the way that I describe this to patients, I think, and it’s easy for them to grasp, is remind them that when they’re outside in bright light or near a window, how well they see up close, they’re less dependent on their glasses. They’re like, “Oh yeah, Dr. McGee, that’s true.” Then I ask, “Do you know why that happens?” They kind of sit there and they’re like, “Not really.” I’m like, “Your pupil is smaller because when you’re in bright light, your pupil shrinks. When you’re in dim light, your people gets bigger to let more light in. We’re just harnessing what the body normally does in natural light, and we’re using that to be able to give you better near vision.” They understand that.

The first few times that I tried to talk to a patient about this and I started doing ray tracing diagrams, I lost them quickly with the pinhole effect. I hear doctors still talk about our spectacle pinholes, but even that’s not really real-world because you lose all your peripheral vision. Our pinholes in the clinic are 1.2 mm. We want to be around 2 mm for the effect to improve near without sacrificing distance vision.

To answer your question, what happened here? We learned to be really intentional about these conversations. What I have learned along this journey is we don’t have to make it hard. This doesn’t have to be a long description or a long dialogue with your patient. It’s as simple as, “I have a drop. Do you want to try it?” I think that was a big learning when Vuity launched is I learned how to be intentional about my conversations. I learned how to get better data.

I listen for the patient who is really frustrated versus the patient who is just maybe a little bothered or just noticing something. There’s an X factor with any presbyopia patient that how motivated they are is what they’re willing to put forth in an effort to tolerate a spectacle lens, such as a progressive add lens. We’ve all had that patient who’s like, “Oh, when I turn my head, it’s blurry.” Or, “I get the fishbowl effect.” We’ve all heard those conversations. Mario, you talked about you’re wearing your multifocal contact lenses. I wear multifocal contact lenses as well. There’s certainly give and take with those.

Mario Nacinovich:

Absolutely.

Selina McGee, OD:

There absolutely is, again, with surgical options and there is with drops, and if you understand, A, this isn’t going to wreck your clinic time, patients deserve to know all of their options. It’s as simple as, “I have a drop, do you want to try it?”

Then a couple of things that you can do in the exam lane, understand where they are with their near vision. I do my distance refraction, I pull the near card down with their distance refraction in place, and I ask what they can actually read with no help in the phoropter. That I never did before prescribing years ago Vuity for the first time. But it gives me an idea of where the patient is because all of these drops have to meet the same metrics. They have to improve vision 3 lines better and near without losing more than 5 letters of distance.

When you have a patient who’s 20/50 uncorrected, I don’t care how old they are, and some of those patients are monofocal cataract patients, right? They’ve got monofocal lenses in, and sometimes I’m surprised how well their near vision is. But if you’ve got somebody that’s 20/50, 20/60, and you know the data behind the drop you’re prescribing, I’m going to improve them 3 lines, that’s highly functional vision versus somebody that’s 20/200 uncorrected, you’re going to have to set different expectations. That 1 little exam element and then getting really comfortable with, “I have a drop, do you want to try it?” It’s really honestly that simple.

I’ve spent the last few years cultivating those conversations and just listening better so that I can provide my patients with education and understanding that presbyopia is a journey that I’m going to be with them the whole way through. Today it might be a drop, and tomorrow, at the end of their journey, it might be refractive lens exchange or it might be cataract surgery with an advanced IOL, but it is a journey. The good news is we have so many options to help them along the journey. Those are all the things that have changed, at least for me, since we’ve introduced this class as therapeutic drops for the first time in presbyopia.

Mario Nacinovich:

No, and I think the journey for the practitioner, like you said, from introducing and maybe overstating and overcomplicating to now being intentional and simple in the nuanced counseling and talking about patient selection as well. Jake, I’m curious, are you finding that patients are coming in and asking about “the drops” they just heard about? Or is this still something that you’re primarily introducing, rather than having them request it by name?

Jacob Lang, OD:

Yeah, I like to think that I’m the one introducing it all the time, but I think more and more our patients are becoming educated from a multitude of avenues, whether that might be direct-to-consumer advertisements or something they saw an ad pop up on their social feed or whatever it is. I still find it’s still something I bring up a lot with patients in my clinic, but I think more and more we’re going to have patients talking about seeing this on direct-to-consumer stuff. I think we’re going to see more and more of a patient saying, “My friend or my colleague, my cousin, whatever it is, is using drops for this. I want to know more about this.” It’s definitely a huge growing category in eye care, and I think we’re going to see patients learning about it in more and more ways.

What a better way to learn about it than from their eye doctor, which is where they should be discussing these things. The worry would be that, hey, they’re hearing about it elsewhere, and are they going to go elsewhere for these opportunities when their provider isn’t discussing these options with them?

Mario Nacinovich:

We’ve talked a little bit about Vuity, and Selina, thanks for highlighting your experience with Vuity from beginning to current. Jake, let’s zoom in on Qlosi specifically, because it’s one of the most recent additions and it has some distinct design features. Can you walk us through what Qlosi is? Its concentration, formulation, the basic dosing strategy. What’s been your experience to date?

Jacob Lang, OD:

Yeah, Qlosi is, I think it was, well, it was the second opportunity for pharmacologic correction. We’re talking about pilocarpine 0.4, as opposed to, I think, was it 1.25 was Vuity? I can’t remember. Selina?

Selina McGee, OD:

Yes, that’s correct. Yeah, yeah.

Jacob Lang, OD:

You’re my math checker, you’re my number checker. We’re talking about a lot less medication, right? Qlosi is walking down the road of less is more, saying, if we do more intentional design to our medication, can we get away with less? Can we use less medication to get the same effect? With this kind of cosmetic, helping our patients do the things they want to do, we really do not want to take away. Right? To your comments, Mario, about we don’t want to take away their distance vision but we want to give them up close vision. Right? We don’t want to steal too much from Paul to pay Peter. That was Qlosi’s intentional design is to give patients a comfortable drop with the least amount of active ingredient to get the job done. That’s where they’ve gone, giving patients a little more flexibility to use a second drop when they need a little boost or a little kicker, but still give them that myosis so that they can improve their near vision.

They’ve designed it with lubricating factors to help the ocular surface and make the drop more comfortable. Less medication to hopefully affect the ciliary body less, which they’ve had some great exciting data about recently. Just have less side effect or poor response or downside to using this drop.

Mario Nacinovich:

Compared to the earlier pilocarpine-based options like Vuity at 1.25%, Qlosi is using a lower pilocarpine concentration and pairs that with a near neutral pH lubricant such as hyaluronic acid and HPMC to improve comfort and tolerability for many patients. That’s got to be good news, especially with all the conversations the 3 of us have had over the years, specifically with dry eye. Given the age of these patients, there’s got to be a concomitant dry eye disorder present, and by the time that they’re using this regularly, maybe they’ll be experiencing dry eye along the way. If you don’t have it already, you ultimately will.

But Selina, from a real-world perspective, how would you describe the onset and feel of Qlosi to the patient? It’s all about expectations, it’s all about being intentional, like you said. When should they expect it to kick in? How long can they reasonably count on functional near vision?

Selina McGee, OD:

Yeah, so, and of course, I love this drop because it’s preservative-free, so that was one of the biggest things that they brought to market that we were all very excited about. All of these newer formulations are preservative-free. Still staying in the pilocarpine moment for this conversation, then we can jump into aceclidine, and then the newest kid on the block, which is carbachol with brimonidine.

For patients and setting expectations, it is really key. When you look at the clinical trials, you’re going to have good near vision within 30 minutes. Then honestly, depending on the patient, you can extend that to 3 to 6, if we’re talking about lens, that’s going to be up to 10 hours. With any of these medications, it is an effect that they’re going to be able to get throughout their working day. That’s really my ultimate goal with this, is I need this to last as long as they’re able to do their activity so that they know when to dose themselves. That’s the other beauty of any of these presbyopia drops, is you put the control back with the patient and allow them to use it when they need it.

With pilocarpine specifically, we saw it with Vuity and you see it a little bit with Qlosi too is you have this adaptation effect. It’s interesting, it fell at 2 weeks with both of them, which happens with contact lenses, which also happens with spectacles. It’s longer for refractive lens exchange or with cataract surgery, that’s like 6 to 12 months typically for neuroadaptation. When you look at aceclidine, there’s no neuroadaptation, at least when you look at their studies. I think it is important just to remind people that their vision is going to be clarified. They’re always going to compare anything we give them to magnification because that’s what’s in reading glasses and that’s what’s easy and they know that. Right? Reminding people that their vision’s going to be clearer but it’s not going to be bigger. That’s a small nuance that doesn’t sound important, but it’s really important.

As patients adapt to clarity versus magnification, that’s how you can present this to patients as far as how they’re going to see with pharmacological options, whether it’s Vuity, Qlosi, I don’t even know how to say the new one, and then of course with Vizz. With any of these, I think just reminding people that the pinhole effect gives them clarity, not magnification.

All those things matter when you’re talking to patients, and it’s a good idea to understand each medication and then develop a little FAQ that you can give to the patient so you’re not the one doing all the heavy lifting. Lean into these companies; they have amazing POP that you can hand to patients so you’re not doing all the education about what to expect. But that’s the biggest thing with any of these drops is making sure you set good expectations and know what that’s going to look like for the patient.

Mario Nacinovich:

Jake, when I think about pilocarpine, I think of a time in my life nearly 30 years ago as a marketer who was competing against pilocarpine and bringing a topical carbonic anhydrase inhibitor in the world of dorzolamide Trusopt to the market in the US. It was easy because we could just talk about safety and side effects of pilocarpine, the headache first and foremost. Safety and side effects always being top of mind, we’ve always talked about this with all the products. What are the most common adverse events you counsel on with patients, with Qlosi and this class in general, and how do you frame that conversation?

Jacob Lang, OD:

Yeah. To the point earlier, we want to do the least amount to our patients, but give them something in return. We want to give them some great near vision. These medications have been designed to be very safe, very comfortable. That’s something we’ve learned as we went, right? I still have patients taking Vuity and are doing really great on Vuity, but we learned from Vuity that we could do better and our patients are asking more from us. Some of the things we want to make our patients aware of with this class of medication is that it’s going to make their pupil smaller, that’s how it works, right? So that they don’t say, “Doc, I put this drop in and it made my pupil really small.” Yep, that’s right. We have to educate them of how it works.

By working on that pupil size, I can do other things. We can see some redness when we put any drop into the eye, but especially with some of the active ingredients involved in making a pupil smaller, they might cause redness. That’s something I always educated patients on. Headache, brow ache is something that’s been reported. We’re seeing less of that now with some of the next-generation drops. It’s less of an issue…

Mario Nacinovich:

I’ve got to think that with the strength of it, it’s got to be less as well, right?

Jacob Lang, OD:

Right, right. Yeah. If you look at the Qlosi data, they’re talking single-digit adverse events where patients are complaining of redness, burning, stinging, and headache. That’s really changed, it’s a lot less, but you just have to learn each medication’s profile and what’s going to work for some patients might not work for others. I think we saw that a lot in dry eye disease, right?

Mario Nacinovich:

Totally.

Jacob Lang, OD:

They would use stinging and burning with Restasis, but then you don’t see it with Cequa or you switch them to Xiidra, and each patient’s experience with each medication varies.

Mario Nacinovich:

Every patient in your chair is an N of 1, and I appreciate both of you that you take such an individualized approach looking at, thinking about their lifestyle, thinking about the behaviors, the psyche of the person, the questions that they’re asking.

I’ve got to ask, do you position these products as an everyday drop? Or I’m curious, is it more of an on-demand option for specific tasks, specific occasions? A bit of both, depending on lifestyle? How do you address this with patients that are asking about these products?

Selina McGee, OD:

Yeah, I think that’s the beauty of the drops is they get to use it on demand, so to speak. One thing we didn’t talk about on side effects before we move off that topic is all of these, because they are a myotic are going to cause some dimness of vision. We did learn that the hard way with Vuity because it didn’t show up in the clinical trials. It was in visual impairment because there was no checkbox for dimming, so we learned that…

Mario Nacinovich:

Oh, okay. It was under a broader category?

Selina McGee, OD:

Yeah, it was under a broader category. None of us knew that. Once we started using it in the wild, then we learned that, and we learned it quickly. That’s something that all of the drops experience. I do always bring that one up with patients is dimming, because we are making the pupil smaller. It’s interesting because even my own experience, my vision is more clear, but it certainly, it just feels like somebody took the rheostat switch and turned it down a notch.

All of these side effects that we talk about, headache, redness, dimming, the stinging on installation, all of those are transient, they all go away. I think that’s another very important distinction with these drops. I think people can sometimes be fearful of side effects, but these are all transient. As long as you know what to expect, the patient knows what to expect. Don’t let that hold you back from prescribing something that’s going to really ultimately help the patient.

Back to your question.

Jacob Lang, OD:

No, I was just going to mention, yeah, one more thing we should probably talk about events is in the older versions, we always worried about retinal damage and tears. What I think we’re really seeing…

Mario Nacinovich:

A lot of caution there in the old days, yeah.

Jacob Lang, OD:

Right. One of the things we’ll touch on there is we’re moving things around inside the eye. Right? We’re moving the iris. Anytime you’re moving things around inside the eye, it might cause some changes and pressure or tension and things like that. We have to be wary of any damage to the retina and the vitreous. We have to be aware of that, we have to educate our patients around that.

As eye doctors, I think it’s much safer because we know what to look for, right? We know to look for issues in the retina. We know how to perform a complete eye exam to look for things like retinal degenerations or high myopes that may be at higher risk for that. Just be the eye doctor, take care of the entire eye and we’ll move on from there.

Selina McGee, OD:

Yeah. I think it’s important, to Jake’s point, to call out that with Vuity, because so many people were excited about that drop, which was a good thing, people were talking about it, but you had a lot of practitioners that were not eye doctors that prescribed this initially. You had patients that should never have been on a pilocarpine-based miotic. I always get asked the question, “Well, why didn’t this show up in the clinical trials?” There was, however, many patients in GEMINI 1 and 2 and VIRGO. What was excluded from that trial is every single patient had a retinal exam. They were all dilated patients.

Mario Nacinovich:

Jake, we’ve talked a lot about pilocarpine-based therapies like Vuity and Qlosi, but the pipeline is bigger than that. Now we’re seeing other mechanisms emerge, including dual-agent and aceclidine-based drops that are designed to refine efficacy, minimize side effects. I’ve heard yet another emerging treatment, Yuvezzi, what has been described as a differentiated, favorable safety and tolerability profile. What can you share about all of these products, and this one in particular? What excites you most about where presbyopia pharmaceuticals are heading over the next year and the next few years?

Jacob Lang, OD:

Yeah, I just think it shows there’s a need, there’s a demand, there’s an opportunity.

Mario Nacinovich:

That’s a good size population, that’s for sure.

Jacob Lang, OD:

It’s a big number. I think that’s the take-home there. I think we’re still trying to figure out how we can do the best for the most amount of patients.

To your comment earlier about glaucoma therapies, right? We don’t have just 1 glaucoma drop.

Mario Nacinovich:

That’s correct.

Jacob Lang, OD:

Why would we have just 1 presbyopia drop? We don’t have just 1 antibiotic. We’re going to need different medications for different patients, for different demands. I think we’re in this kind of discovery era of refractive pharmaceuticals to find out what works best for who and where, and what the effects are of these different things. We’re seeing that kind of area of discovery and trying to find out what works best for the most patients.

Mario Nacinovich:

Any one particular, in terms of these emerging mechanisms, that is exciting you the most?

Jacob Lang, OD:

Yeah, I think they’re all exciting. I don’t know, there’s a lot of data to be published and released yet, so I really can’t say. I do like the trend moving forward where Qlosi is moving toward less for more, less drug, preservative-free. I love where VIZZ is going with, hey, we want to give the patient a longer effect. We don’t want them to have to put drops in. We want to get a longer effect, we want to give them the whole work day. I think the pharmaceutical companies are trying to tap into what our patients want and deliver on their wants and their needs. I’m just excited to see if we can deliver more for our patients.

Mario Nacinovich:

Well, let’s talk about that. That’s been a topic we’ve been dancing around for this entire conversation, but let’s talk about who is and who isn’t a good candidate. Selina, if you think about that classic early to moderate presbyope walking into your office, what are the key criteria you’re looking for when you’re considering a presbyopia drop and having that intentional conversation with them?

Selina McGee, OD:

I mean, the low-hanging fruit, of course, is your emmetropic presbyope who’s frustrated. The lowest hanging fruit is your post-LASIK patients. They’ve already invested to not wear glasses or contact lenses. They show up in our practices and say, “My LASIK’s worn off. I need you to fix it.” That is a really great patient. Again, emmetropic presbyopes, low-hanging fruit.

But then, beyond that, you start to get into your advanced IOL patients that just need a bridge therapy. You get into multifocal contact lenses, especially toric multifocal contact lenses, that’s a lot of optics to put in a lens. But maybe you can…

Mario Nacinovich:

That is me.

Selina McGee, OD:

Right? Maybe you can keep them in a toric lens that is, and then you add your presbyopia drop to help with the near and buy a little bit more time. I’m always looking for the patient who honestly is frustrated. That’s my biggest piece, if they’re frustrated in their day-to-day life every single day, then they’re a candidate. Here’s the key piece. Maybe they’re not a candidate today, but they will be tomorrow. It really behooves us to start this conversation early and have it often because they need to hear it multiple times. As we’ve talked about, with each iteration of pharmacological therapies, we learn more, we get better, we play less with the ciliary body, like with aceclidine. We know with the newest one, that’s the dual-agent, now you’ve got brimonidine and carbachol. We’ll look and see what that looks like in the wild. Nobody has access to it as of this recording, so we don’t know what that looks like, but the clinical data, we just get better and better.

My biggest takeaway here is, don’t prejudge the patient. They deserve to know that this is an option. The last thing that you want to have happen is what Jake started off the conversation with, is your patient leaves your office and doesn’t hear it from you. That’s the worst possible outcome, I believe, in this scenario.

Mario Nacinovich:

Then trust is broken. Yeah, absolutely. Jake, do you look at it differently, in terms of age range or refractive status or you and I’ve talked a lot about ocular surface health?

Jacob Lang, OD:

Yeah, yeah. I think we want to maximize ocular surface help them. We always want to take care of our patient, the entirety of the patient’s eye and vision.

Some of the other things I think about is patients that are frustrated. I think that’s the big one is need and frustration. Finding patients that are frustrated and open to do something else. I think Selina’s question of, “I have a drop, is that something that would interest you? Would you be interested in using this?” I think that opens the door to that conversation so well, that I think that’s just an easy one to knock out and talk to them about.

There’s going to be a lot of interesting things that we do with this in the future too. We get to be the doctor, we get to play with this stuff. We might have patients that have irregular corneas and are doing better. To Selina’s point, maybe IOLs and contact lenses, this has as a role. It’ll be interesting to see how this develops in that off-label space as well, to help patients’ vision in other things besides the emmetropic presbyope. But I think just numbers of presbyopes is just going to overwhelm us with just trying to get this taken care of for most of our presbyopes.

Mario Nacinovich:

Jake, where do you say, “Hey, there’s a red flag.” Pharmacologic presbyopia therapy or refractive pharmaceuticals, as you said, may not be the right first-line choice for this patient?

Jacob Lang, OD:

Yeah, I think if there’s other pathologies, whether it be ocular surface disease, whether it be significant glaucoma, whether it be those high myopes, a peripheral retinal disease, but also central retinal issues, right? Patients that have some abnormal vitreous adhesions or macular pathologies, those probably aren’t our best patients. Just like they’re not for multifocal IOLs, they’re probably not our best candidates for pharmacologic correction for presbyopia either. Just be the doctor and say, “Eh, this probably isn’t your best option.”

Mario Nacinovich:

We’ve talked about expectations throughout this conversation. Jake, how do you script that conversation so patients understand they’re likely to improve their near vision maybe to something like functional 20/40 near a large portion of their cases, but that is not a 20-year-old’s accommodative system in a bottle.

Jacob Lang, OD:

Yeah, I kind of explain it like, “This is going to help you see better. You’re going to see better up close. It’s not going to make your eyes 20 years old again. It doesn’t regrow hair, it doesn’t make your knees more flexible.” Right? I think Selina’s point too, it doesn’t give you the magnification. It doesn’t make things bigger. Right? It makes you see better up close without using that. Stressing the without component of it, you see better without going to get your readers. You’re going to see better without putting your multifocal contacts in. It does that without these other things. It can be in addition to with contacts and things like that, but that’s how I explain it is, “This is not the fountain of youth, but it’s an opportunity to improve things.” I think that sets the limitation of like, “Hey, it’s making things better, but this is not a cure. We haven’t found a cure for birthday candles yet.”

Mario Nacinovich:

We are emphasizing functional, not perfection.

Jacob Lang, OD:

That’s exactly right.

Mario Nacinovich:

In this case, can you each share a brief, perhaps an anonymized case that really illustrates a success story, maybe even one where you learned the importance of tighter counseling, like you had said earlier, Selina or Jake, like we’ve just talked about, different patient selection.

Selina McGee, OD:

Yeah. I mean, I can share a story early days of Vuity, of something that this is why I think it’s so important that we talk to patients about who’s not a candidate. I had a patient who I hadn’t seen in 2 years. He’s a –6 myope with lattice degeneration. Normally, I would see someone like that every 6 months, but he was non-compliant, and I hadn’t seen him in 2 years and he took his wife’s Vuity, and then promptly had a retinal detachment. Whether the drop caused it or not, he should never have been on that drop in the first place.

Mario Nacinovich:

That’s definitely a recommendation we make to every patient who may be listening in.

Selina McGee, OD:

Absolutely.

Mario Nacinovich:

This is not professional advice. You should be utilizing the opportunity to have these conversations with your eyecare practitioners and certainly never use something that is prescribed to someone else.

Selina McGee, OD:

Correct. I think there is this notion because these are drops that improve what someone might say a cosmetic improvement, but these are pharmacological drops. You need a prescription; you need to be seen. I tell patients when they’re not a candidate, “There are drops in the market that will help you see better up close, you are never to take those. That is not for you, at least with the current options that we have.” I think that’s the other part of this conversation that I want doctors and patients to hear is, they might be out to dinner one night having, “Well, try this drop. It works great.” They need to know that they’re not a candidate for that. That’s one of my early learnings, that’s how not to do things, but none of us had control over that. That was the patient’s choice.

Then the second piece is, I’ve had so many patients that will say things like, “Oh my gosh, this drop is amazing. It’s like changed my life. I don’t have to have reading glasses on all the time. I have 10 reading glasses strung in every room. I never know where they are. It’s so frustrating. I need a 150 for here and a 250 for here.” Meanwhile, they’re a 42-year-old presbyope who really needs a plus 75. There is those patients who are so excited that they have a different type of technology.

Jake touched on this a little bit earlier. This is a yes-and. We have to move away from this notion that patients only get one option. They need spectacles, they need computer glasses, they need and deserve to have contact lenses, single-vision and multifocal, and they can have a drop for when they don’t want to have to rely on spectacles and contact lenses. Then we eventually might move into surgery, but we have to get away from this notion that there’s a one-size-fits-all. This is a yes-and.

Mario Nacinovich:

No, I definitely appreciate that. Jake, any piece that you’d like to share, any success story?

Jacob Lang, OD:

This is actually a friend, golfing buddy, that’s also my financial guy. We were going over Excel spreadsheets and numbers and all these things, and I could totally tell he was struggling to see the numbers and the decimal points and those sort of things. I had mentioned to him like, “Hey, buddy, you’re older than me, let’s do something better.” He wasn’t using readers; he felt like he could get by without it.

When we did an exam, gave him this opportunity, he was like, “Wow, I didn’t know what I was missing and I didn’t know how good it could be.” This is a patient that was avoiding readers. He was actually a low hyperope, but it really gave him that wow effect of, maybe this is a male thing but, “I’ve been stubborn, I’ve been ignoring this, I’ve been powering through this.” You give them this as their first thing to do to make things better and allow them to see that, “Oh, I didn’t know how good this could be,” is pretty exciting and enlightening and such a success story to have them saying, “Dude, I can see again and I don’t have to blow it up to 250% zoom.” That was a great case. It’s always friends, family, staff that we lean on so much when we’re trying new things and leaning on things. I’ll never forget how impressed he was as his first gateway drug, if you will, to presbyopia correction.

Mario Nacinovich:

Before we close, I want to have a quick conversation with both of you about practice management. What have you found helpful for integrating these therapies and things like staff education, scripting at the front desk? How do you handle access, cost conversations, pharmacy logistics? Is that all handled by someone else or are you taking a personal step in that process?

Selina McGee, OD:

I mean, it starts at the top, right? We have to educate everybody along the way. Then you bring in your whole team that you delegate each of this piece to so that you’re not doing the heavy lifting. It goes to the front desk. I mean, and there is a lot of DTC. I remember when Vuity did their DTC launch, we probably had 8 to 10 calls a day, have patients that were like, “Oh my gosh, I want to try this drop. Can I come in for an exam?” Your front team has to know what you’re offering in the back.

Then it goes all the way through to education and lean on your partners in industry. If they have a great POP you can hand out, you can certainly make your own. I mean, those are all the things that we have done. Patients can only hear so much in the office. I like to give them everything that they can to read at home, to lean into with a QR code or whatever that is, so that you’re not doing the heavy lifting. Literally, my conversation is, “I have a drop. Do you want to try it?” Then someone else runs with it from there.

Jacob Lang, OD:

Yeah. I just tell them, “I’m prescribing this medication for you. If you have any questions, call Selina’s office and their staff is so educated that they’ll help you.”

Mario Nacinovich:

There’s a great doctor in Oklahoma you can contact.

Jacob Lang, OD:

Just call them with questions. No, seriously, we want to educate the patients the best, but yeah, it takes a village. Right? I think it takes everyone. Our staff needs to know what’s new, what’s coming.

I think we learned the DTC, the direct to consumer stuff with Vuity I think was really eye-opening, pun intended, with how much our patients are asking for this. I think we’re going to see more of that again in the future. I think it’s important that we as eyecare providers talk to our staff, talk to our technicians, talk to our front desk people, the people that answer the phones, so that they know what presbyopia is, they know how these drops work, because patients are talking to them many times more often and more frequent than they’re talking to the doctors. They need to be part of our team, they need to be part of our village so we can answer questions and know what’s going on and be ready to take care of this when patients call with questions and thoughts.

Selina McGee, OD:

Make sure your opticians, that’s the one list we haven’t named yet. Make sure your opticians, I mean, they’re the ones that are filling your prescriptions. They can certainly have a conversation around this and they’ll be the ones answering a lot of questions and they are very familiar with presbyopia because they’re fitting lenses with presbyopic corrections. There’s another opportunity to make sure they’re well-trained and well-educated.

Mario Nacinovich:

As the son of a practice manager for an optometry practice, my mom of 30 years, she would appreciate that question. Mom, that one was for you.

Jacob Lang, OD:

Early Mother’s Day, I love it. Yeah, but yeah, there’s so much more of this. It’s going to be interesting how…I found our reps aren’t just for talking to the doctor and giving samples. They can do a lot of education to our staff too. Leaning into other people besides just you to delegate some of that education is an opportunity.

Mario Nacinovich:

I think that’s an untapped resource, and certainly, with my ties to the pharmaceutical world, I certainly appreciate you saying that, Jake. Certainly, this overall has been a fantastic conversation. For those of you who have stayed with us throughout this entire podcast, before we wrap, I’d like to give each of you a quick clinical pearl question.

Jake, if you had the opportunity to provide one concise message to both peers and presbyopes listening to this episode, what should they know about options in 2026, regarding these products?

Jacob Lang, OD:

Yeah, I think the biggest thing is educate your patients before somebody else does. Educate your patients before commercials do, educate your staff before commercials do or someone else does, because it really builds that trust and makes the patient look to you as a leader in education, a leader in knowing what’s new, what’s upcoming, really looks to you for their eye care. That’s my pearl, would be educate your patients before they become presbyopic. There’s only so much you can say to a 35-year-old with a stable myopic prescription. Right? It’s an opportunity to educate them about what’s next. “Hey, 5 years from now, you’re going to lose your up-close vision and there’s some opportunities to do more than just those big old bifocals your grandpa wears.”

Mario Nacinovich:

Absolutely. Selina and Jake, thank you both for sharing your insights and real-world experience in presbyopia, or as Jake put it, refractive pharmaceuticals.

For our listeners, if you’re noticing that your near tasks are getting harder, don’t just grab those cheapest pair of readers off the rack, please talk to your eyecare provider yourself as well. If you’re outside of eye care, talk to them about the full spectrum of presbyopia options, including emerging pharmaceutical therapies like Qlosi and other presbyopia drops that might fit your lifestyle and visual needs.

I’m Mario Nacinovich, and this has been yet another eye-opening episode on The Spotlight Series. Thanks for listening, and we’ll be sure to see you on our next episode.