Presbyopia: glasses, contact lenses, eye drops and lens surgery — what each option has been tested on

Somewhere in the forties, most people start holding a menu further away. This is presbyopia: the gradual loss of the eye's ability to refocus from far to near. It is not a disease in the usual sense, and none of the options below has been shown to give the lens its flexibility back. But there are now more ways to work around it than reading glasses alone — including eye drops approved in the last few years, and lens surgery done to reduce dependence on glasses. This article goes through what each option has been tested on, what the trials measured, and where the trade-offs are.

What changes in the eye

To see something close, the eye has to add focusing power. It does this through accommodation, in which the crystalline lens changes shape. On the leading account, the lens stiffens with age and the range of accommodation shrinks, until near work at a normal reading distance no longer comes into focus without help. A 2024 review treats the exact mechanism as still debated, and it involves structures around the lens as well as the lens itself. How much the loss matters in daily life also depends on the eye's own refraction: the global estimate below adjusts its model for how common short-sightedness is.

The scale is large. A 2018 systematic review and modelling study estimated that about 1.8 billion people worldwide had presbyopia in 2015, and that 826 million of them had impaired near vision because they had no correction or inadequate correction. The unmet need was greatest in rural areas of low-resource countries.

Glasses: still the reference option

Reading glasses, bifocals and progressive lenses correct near vision without touching the eye. Progressive lenses change power gradually from the top of the lens to the bottom, so the wearer looks through different zones for distance, intermediate and near.

None of these options changes the eye, which is why they are the baseline against which everything else is compared: whatever a drop or an operation offers, it has to beat glasses on something that matters to the person, and not only on convenience.

Contact lenses: multifocal designs and monovision

Contact lens options include multifocal (simultaneous-vision) soft lenses, rigid designs and monovision, where one eye is corrected for distance and the other for near.

• A 2023 systematic review found 16 randomised clinical trials of presbyopia-correcting contact lenses, most of them with a crossover design.

• Monovision relies on the brain favouring whichever eye is in focus. The cost is some loss of binocular function, including depth perception, and not everyone tolerates it.

What that review does not show is which design is best for a given person. The limits it names are small samples in some trials and little information on how the size of the near addition affects performance.

Eye drops that narrow the pupil

Several eye drops have now been approved in the United States for presbyopia in adults, among them pilocarpine 1.25% in 2021 and aceclidine 1.44% in 2025. The pilocarpine results below are from trials of the 1.25% drop; the aceclidine results come from a meta-analysis of topical aceclidine, alone or combined with another drop. Both constrict the pupil, which increases depth of focus — a "pinhole" effect — and neither is described as restoring the flexibility of the lens. They are not identical: according to their labels, pilocarpine also acts on the ciliary muscle, while aceclidine acts mainly on the iris. The trials did not measure whether either drop slows presbyopia.

Pilocarpine 1.25%, the GEMINI 1 trial. 323 adults aged 40 to 55 with presbyopia, at 36 sites in the United States, used the drops or an inactive vehicle once daily for 30 days.

• On day 30, three hours after the dose, 30.7% of the pilocarpine group (50 of 163) gained three or more lines of distance-corrected near visual acuity in dim (mesopic) light, against 8.1% (13 of 160) with vehicle.

• At six hours the same measure was 18.4% and 8.8%. At eight hours the difference on this main measure was no longer statistically significant.

• The onset of the effect was reported at 15 minutes after the drop.

Twice-daily pilocarpine, the VIRGO trial. 230 adults aged 40 to 55 used the drops or vehicle twice a day, six hours apart, for 14 days. On day 14, three hours after the second dose, the share who gained three or more lines of distance-corrected near acuity in dim light without losing more than five letters of distance acuity was 27.3 percentage points higher with pilocarpine. Headache was the most common side effect: 8.8% with pilocarpine versus 3.4% with vehicle.

Aceclidine. A 2026 meta-analysis of five randomised trials with 883 participants found that aceclidine made a gain of three or more lines of near vision much more likely than placebo. Side effects were also more frequent than with placebo, and the authors note that the trials were few and short.

What these trials do not say:

• They are short. GEMINI 1 lasted 30 days and VIRGO 14 days, so long-term use is not described by them.

• They measure a gain in lines on a chart, not whether people stop needing glasses in daily life.

• Most participants were in their forties and early fifties, and the drops act for hours, not all day.

There is also a safety signal that the trials were too small to measure. Constricting drops have long been suspected of raising the risk of retinal detachment, and a case series from 2022 described retinal detachments in three eyes of two men who had started pilocarpine 1.25% for presbyopia weeks earlier. A case series cannot show how often this happens or prove cause. The authors wrote that doctors should consider a dilated retinal examination before starting, particularly in people who are short-sighted, and should tell patients about warning symptoms: flashes, floaters and loss of part of the visual field.

Replacing the lens

The only irreversible option is surgical: removing the natural lens and implanting an artificial one (an intraocular lens). Replacing a clouded lens is routine cataract surgery, and the standard implant is a single-focus (monofocal) lens. Lenses with several focal points or an extended depth of focus are an alternative implant, not the default. When the operation is done without a cataract, only to reduce dependence on glasses, it is called refractive lens exchange.

The best-summarised evidence comes from cataract surgery. A 2016 Cochrane review found 20 randomised trials that enrolled 2,230 people having cataract surgery. Most compared multifocal lenses with monofocal ones; two compared them with monovision. The findings below are from the comparison with monofocal lenses:

• Distance vision was similar with both (moderate-certainty evidence).

• People with multifocal lenses may have had better unaided near vision and may have been less dependent on glasses (low-certainty evidence).

• Glare and haloes were more common and more troublesome with multifocal lenses; for haloes the risk was more than three times higher (moderate-certainty evidence).

The reviewers concluded that whether better near vision outweighs these side effects varies from person to person.

Two points matter when this evidence is used to think about lens surgery for presbyopia alone:

• The trials were in people who already had cataracts. In a clear lens, the operation removes a lens that still works for distance, and the same balance of benefit and harm has not been shown for this group.

• Lens surgery carries a risk of retinal detachment afterwards. In one retrospective single-centre study of 421 patients younger than 61 who had cataract surgery or refractive lens exchange, retinal detachment occurred in 3.55% of eyes over an average follow-up of about four years, and a longer eye (a marker of short-sightedness) was a significant risk factor.

Techniques on the cornea and newer lens designs also exist; reviews describe them, but they share the same underlying trade-off: extending the range of focus in one way usually costs something in contrast, night vision or binocular balance.

What this means for a decision

Presbyopia is not dangerous, and every option above is a choice between trade-offs rather than a treatment that changes the course of the condition. A few things follow from the evidence:

• Glasses and contact lenses change nothing in the eye and can be adjusted as the need for near correction grows.

• In the pilocarpine 1.25% trials, in adults aged 40 to 55, more people gained lines on a distance-corrected near chart for several hours than with an inactive drop, and those trials lasted 14 or 30 days. That is not the same as correction through a whole day, and the question of the retina is worth raising with an eye doctor before starting a pupil-constricting drop.

• Lens replacement is irreversible. The strongest evidence for multifocal lenses comes from people with cataracts, and in a clear lens the case rests on preference rather than on medical need.

Near vision that changes gradually with age is expected. Flashes of light, a sudden shower of floaters, a shadow or curtain across part of the field of view, or a sudden loss of vision in one eye are different: they are reasons for an urgent eye examination the same day, regardless of which correction you use.

For other checks worth considering at this age, see which screening tests after 40 have been shown to change outcomes.

This material is for information only and does not replace a consultation with an eye doctor.

Sources

• Fricke TR et al. Global prevalence of presbyopia and vision impairment from uncorrected presbyopia: systematic review, meta-analysis, and modelling. Ophthalmology. 2018. PMID 29753495

• Davies LN et al. BCLA CLEAR presbyopia: mechanism and optics. Contact Lens and Anterior Eye. 2024. PMID 38796331

• Morgan PB et al. BCLA CLEAR presbyopia: management with contact lenses and spectacles. Contact Lens and Anterior Eye. 2024. PMID 38631935

• Molina-Martín A et al. Efficacy of presbyopia-correcting contact lenses: a systematic review. Eye & Contact Lens. 2023. PMID 37418305

• Evans BJ. Monovision: a review. Ophthalmic and Physiological Optics. 2007. PMID 17718882

• Waring GO 4th et al. Safety and efficacy of AGN-190584 in individuals with presbyopia: the GEMINI 1 phase 3 randomized clinical trial. JAMA Ophthalmology. 2022. PMID 35238902

• Kannarr S et al. Safety and efficacy of twice-daily pilocarpine HCl in presbyopia: the VIRGO phase 3 study. American Journal of Ophthalmology. 2023. PMID 37149245

• Ibrahim T et al. Efficacy and safety of aceclidine in presbyopia: a systematic review and meta-analysis. Seminars in Ophthalmology. 2026. PMID 42574210

• Al-Khersan H et al. Retinal detachments associated with topical pilocarpine use for presbyopia. American Journal of Ophthalmology. 2022. PMID 35609677

• de Silva SR et al. Multifocal versus monofocal intraocular lenses after cataract extraction. Cochrane Database of Systematic Reviews. 2016. PMID 27943250

• Laube T et al. Pseudophakic retinal detachment in young-aged patients. PLoS One. 2017. PMID 28859157

• Schnider C et al. BCLA CLEAR presbyopia: management with intraocular lenses. Contact Lens and Anterior Eye. 2024. PMID 39068141

• Craig JP et al. BCLA CLEAR presbyopia: management with corneal techniques. Contact Lens and Anterior Eye. 2024. PMID 38851946