Presbyopia: The Holy Grail of Ophthalmology?

I was once told that the biggest unmet need in advanced countries for vision correction solutions is for presbyopia. The loss of closer vision during the middle age years has become more frustrating as we become more time dependent on our phones and computer screens. Glasses and contact lenses are of course the first line fix but in recent years a wave of surgical and pharmacological options have emerged -  from corneal tweaks to cutting‑edge eye drops.

A perfect solution is perhaps never achievable – hence the search for the ’Holy Grail’.

Corneal Procedures: CRK and CK

One of the earliest attempts to tackle presbyopia surgically was Corneal Refractive Keratoplasty (CRK). The idea was simple: reshape the cornea with tiny incisions or laser patterns to create a multifocal effect. While it worked to some degree, results were unpredictable and often faded over time. CRK is not performed today, but it paved the way for more advanced techniques. I have seen a number of patients of the years who had the surgery done, usually overseas, many years before and the RK incisions and changes in corneal shape pose interesting problems for vision correction particularly as these patients come through for cataract surgery.

Conductive Keratoplasty (CK) came next, using radiofrequency energy to shrink collagen in the cornea’s periphery, steepening the center and improving near vision. It was quick, office‑based, and minimally invasive. The downside? Results often regressed within a few years, and some patients developed visual distortions. The corneal topography maps are interesting !

LASIK Variants: Monovision, PresbyLASIK, and Beyond

LASIK is not just for myopia or astigmatism — it has also been adapted for presbyopia. The most common approach is monovision LASIK, where one eye is corrected for distance and the other for near. It’s effective and predictable, but some people struggle with reduced depth perception. A contact lens trial beforehand usually helps patients decide if they can adapt. I recommend the rule of thirds when considering monovision – one third of people love it, one third of people hate it and one third of people find it so-so. I would only consider surgery for patients who have tried monovision beforehand and really liked it.

Then there is PresbyLASIK, which sculpts the cornea into a multifocal surface, giving both near and distance vision in the same eye. It can work well, but some patients notice halos, glare, or reduced contrast. The main problem I see is that the effect does not last and then patients come in for a lens replacement procedure and the lasik has messed up the corneal pattern for calculations. Certainly, in my book, not an option for patients over 55 years old.

A more experimental twist is INTRACOR, where a femtosecond laser creates concentric rings inside the cornea without touching the surface. It is minimally invasive, but concerns about long‑term stability and biomechanical weakening have limited its uptake. PRK variants also exist, using surface ablation to create multifocality, though recovery is slower than LASIK.

Intracorneal Inlays

Corneal inlays had their moment in the spotlight, especially the Kamra inlay, which was FDA‑approved in 2015. It works like a pinhole camera, increasing depth of focus and improving near vision while preserving distance clarity. Other inlays, like the Raindrop, aimed to reshape the cornea but were withdrawn due to late‑onset haze. means that these are no longer realistically used. I did some surgery with corneal inlays over 20 years ago and the same problems which occurred then , such as instability, rejection and corneal haze , still persist in the later iterations and versions.

Intraocular Options

For patients already considering cataract surgery, intraocular lenses (IOLs) are a natural solution. Multifocal and extended depth of focus (EDOF) IOLs split light to provide both near and distance vision  Accommodative IOLs, designed to mimic the eye’s natural focusing ability, were used about 15 years ago — some improvement in focusing range, but not true accommodation.  The main issue was variable outcomes and some changes in refraction and instability of the lens power over time; Experimental intraocular rings and implants have  also been studied.

Pharmacological Therapies: The New Frontier

Perhaps the most exciting recent development has been the arrival of presbyopia‑correcting eye drops. In 2021, the FDA approved Vuity™ (pilocarpine 1.25%), the first of its kind. By constricting the pupil, it increases depth of focus, giving patients clearer near vision for about 4–6 hours. Side effects can include headaches, eye redness, and reduced night vision, but for many, it’s a game‑changer.

Building on that, Qlosi™ (pilocarpine 0.4%) was approved in 2023. Its lower concentration aims to reduce side effects while maintaining effectiveness. Other drops are in the pipeline too — combinations like carbachol with brimonidine to extend duration, and even lens‑softening agents like UNR844, which target the stiffening lens itself. These could one day offer a more fundamental fix rather than just a temporary workaround.

Are there any concerns? Well, yes. When I started as a junior doctor we had many patients in our clinics who had been on long term pilocarpine for glaucoma. It was not a pleasant therapy … eye aching, headaches and actually difficulty in focusing. Risks of long term pupil constriction and a very small risk of retinal detachment in myopic individuals.  These trials use a much lower concentration of the pilocarpine so side effects should be less but patients should be appropriately selected and counselled.

At time time of writing ( October 2025), these options are not available in the UK.

Putting It All Together…

So where does that leave us?

The answer is - where we started - there is no magic cure for presbyopia and all options are a compromise….

Corneal procedures like CRK and CK are mostly historical footnotes, while LASIK‑based approaches remain useful for carefully selected patients. Inlays had promise but stumbled on safety issues. Intraocular lenses dominate for those undergoing cataract surgery, offering reliable spectacle independence. And now, pharmacological therapy has entered the scene, giving patients a non‑surgical, reversible option that fits neatly into daily life.

Presbyopia isn’t going away — it’s a universal part of aging — but the toolbox for managing it is bigger and more versatile than ever. From quick‑acting drops to permanent lens implants, the future looks increasingly tailored, with options to match different lifestyles and visual needs.