February 2018


Presentation spotlight
Topical accommodating eye drops

by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer

Dynamic imaging of accommodation by swept source OCT shows a difference of 50 µ pre- and post-drop.
Source: Jorge Alio, MD

Change of 120 µ is seen in anterior chamber depth pre- and post-drop using UBM.
Source: Felipe Vejarano, MD

New study demonstrates better near vision and high patient satisfaction in presbyopic patients using topical drops, with unchanged distance vision

Improving near visual acuity without compromising distance is the ultimate treatment goal in patients upward of 40 years of age experiencing a reduction in their accommodative power. However, getting there can be complicated. Surgical approaches to presbyopia achieve visual improvements but involve less than perfect near or distance visual acuity, limiting efficacy and requiring at least some degree of spectacle dependence. Nonsurgical approaches to presbyopia address different aspects of the accommodative process, such as monovision, parasympathetic mediated meiosis and ciliary muscle stimulation, or lens softening, which restores the lens’ shape changing ability. However, these approaches aren’t ideal either. Pure parasympathetic treatments result in a relatively small pupil diameter and a myopic shift, compromising far distance vision. They also cause well-known adverse reactions from the muscarinic stimulation of the ciliary muscle and pupillary sphincter. Monovision, despite its appeal for achieving good vision at different distances, is less effective in reduced light conditions compared to a binocular approach, so the drawbacks of current presbyopic treatment approaches go on and on.

Observational study

An observational study presented at the XXXV Congress of the ESCRS titled “Symptomatic control of presbyopia through pharmacological ciliary body stimulation” described excellent outcomes using a topical treatment with FOV Tears, which seems to improve near vision for hours at a time, without the usual compromising of distance visual acuity. According to Felipe Vejarano, MD, Fundacion Oftalmologica Vejarano, Popayan, Colombia, who developed the presbyopic drops, seeing is believing.
“FOV Tears improved vision by two to three Snellen lines for near in the short term and by one to two additional lines, with continuous use,” Dr. Vejarano said. “This treatment improves the physiological deterioration of accommodation with age. We even saw an improvement of one line of visual acuity for distance vision and extraordinary intermediate results of 20/25 or better.”
The observational study included 588 eyes of 294 patients, of which 157 (53.4%) were male and 137 (46.6%) were female, who received FOV Tears twice daily, in their first application of the drug. The age range was 40 to 71 years (average 51 years). Their average refractive defect pre-drop was sphere +0.54 D and cylinder –0.46 D. The patients had associated findings that included: diabetes three (1.02%), amblyopia three (1.02%), glaucoma one (0.34%), forme fruste KC 12 (4.08%), and dry eye 19 (6.46%); and previous surgeries: RK or AK six (2.04%), LASIK 54 (18.37%), intrastromal rings 2 (0.68%), and pseudophakia four (1.36%).
The study data revealed that the difference between the sphere pre-drop and 2 hours post-drop was less than one-tenth of a diopter (–0.09 D) and the difference in the cylinder was even lower (–0.03 D), ruling out a myopic shift. The ocular scatter index was 0.87 pre-drop and 0.69 post-drop (difference 0.18).
Pupil size measured using the NIDEK AL-Scan (NIDEK, Gamagori, Japan) revealed a pre-drop pupil size of 3.26 mm and a post-drop pupil size of 3.22 mm under photopic conditions (difference of –0.04 mm), and a 4.77 mm pre-drop pupil size and 4.15 mm post-drop pupil size under scotopic conditions (difference of –0.62 mm), indicating a non-fixed meiotic, dynamic pupil that changes size in accordance with differences in the light intensity.
“This treatment allows a truly improved physiological accommodation,” Dr. Vejarano said. “FOV Tears is an ideal pharmaceutical and topical therapy that is truly accommodative, not pseudoaccommodative. It improves near vision, but also far vision, or at least doesn’t alter it. We saw a dynamic pupil in different light conditions, not fixed meiosis. The treatment caused a mild and controlled dynamic meiosis that also could diminish glare (dynamic pseudoaccommodation), not an extreme and fixed meiosis that decreases contrast sensitivity.”
Distance binocular vision was 20/30 or better in 95.69% of the patients pre-drop and 98.76% post-drop, and 20/25 in 87.69% and 95.03%, respectively. Near binocular vision post-drop was 20/40 (J3) or better in 91.52% of patients, 20/30 (J2) or better in 80.57%, and 20/25 (J1) or better in 54.06% of the study patients.
Tested monocularly, 62.54% of the patients gained three or more Snellen lines, while 37.1% gained three lines or more binocularly.

Pilot study

Dr. Vejarano reported the 3-month follow-up findings of a pilot study in 40 patients (age range 40 to 67 years, average age: 51 years) using FOV Tears, that described an increase of 0.75 D in accommodation amplitude initially, increasing up
to 1.5 D with continued use of the drops up to 3 months. Accommodation was measured to be 1.5 D, improving with time of use up to 2.5 D. The results mirror those achieved in the 14 presbyopic patients that constituted a previous pilot study using FOV Tears coauthored by Dr. Vejarano as reported in the literature.1
Accommodation improvement shown by defocus curve revealed an accommodation amplitude that got wider with continued use over time. Near vision J3, J2 was achieved in 100% of the patients by the third month of treatment, and J1 was achieved in 67% by the third month.
“Near visual acuity regresses at about 8 hours following drop application. The measurable improvement in near vision decreases at about 10 hours after drops are given,” Dr. Vejarano said.
Scheimpflug photography demonstrated decreased anterior chamber depth as well as anterior displacement of the lens. UBM corroborated the decreased anterior chamber depth as well as an increase in the length and thickness of the lens.
A satisfaction survey showed that in terms of near vision correction for normal everyday activities, 43.75% of the patients were spectacle independent after the first week. This increased steadily to 100% satisfaction by the second and third months post-drop.
“I have been using these drops for 7 years, twice a day in presbyopic patients,” Dr. Vejarano said. “In 2013 my amplitude of accommodation was 1.75 D, in 2015 it was 2.50 D, and in 2017 it was more than 3.5 D. The accommodation range is making these eyes younger.”

FOV Tears

FOV Tears is a patent pending eye drop combination that uses a parasympathetic agent, an NSAID, two alpha agonists, and an anticholinesterase agent to stimulate the iris and ciliary muscles, and promises to minimize the drawbacks associated with a purely parasympathetic approach. The drops are given bilaterally to avoid the scotopic disadvantages seen with monovision.
“The treatment stimulates the contraction of the ciliary body and maintains a physiological pupil diameter variation. In this context, binocular vision avoids worsening of visual performance in reduced light and allows physiological image merging with clear focus at near, intermediate, and distance,” Dr. Vejarano said.


1. Renna A, et al. Pharmacological treatment of presbyopia by novel binocularly instilled eye drops: A pilot study. Ophthalmol Ther. 2016;5:63–73.

Editors’ note: Dr. Vejarano has financial interests with FOV Tears.

Contact information

Vejarano: felipev@fov.com.com

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