As of the writing of this post (February 2026), we now have FOUR FDA-approved prescription eye drops for presbyopia in the US. Presbyopia is the fancy name for the natural, age-related decline in our focusing ability, which manifests itself as difficulty with near vision. This usually occurs around the early to mid forties. Last week, the FDA approved Yuvezzi (carbachol 2.75% and brimonidine tartrate 0.1%), the fourth of the presbyopia eye drops but the first dual-agent presbyopia drop.
How do these presbyopia drops work?
The short answer: All four of these drops treat presbyopia by reducing pupil size. Smaller pupil size increases depth of focus, sharpening vision (aka the pinhole effect). Two of the drugs use pilocarpine to do so, while one uses aceclidine and the last uses a combo of carbachol and brimonidine tartrate. I’ll go into more detail about each drug below, but they work very similarly.
Tell me more.
If you insist! Let’s break down all four of the presbyopia drops we have FDA approval for here in the US, as of February 2026.
Vuity™ (pilocarpine 1.25%)
- FDA approved in 2021
- The long answer to “how does it work”: Pilocarpine is a non-selective cholinergic agonist, meaning it activates acetylcholine receptors. These receptors are in the iris, ciliary body, and retina. So pilocarpine contracts the iris sphincter muscle and the ciliary body muscle. The iris contraction reduces the pupil size- that’s what we want. Because pilocarpine is non-selective, it also causes contraction of the ciliary body muscle, which is not ideal. The ciliary body contraction causes lens thickening and anterior displacement, which can cause a myopic shift (potentially impacting distance vision and causing vitreoretinal traction that can lead to a retinal tear or detachment), as well as accomodative spasms that can cause browaches/headaches. More on that later. The ciliary body contraction also increases drainage of aqueous fluid via the trabecular meshwork; this latter effect is why this drug has been used in glaucoma therapy for a long time.
- Efficacy: Onset as early as 15 minutes, up-to-9-hour efficacy with twice-daily dosing
- Who was included in the study? People age 40-55, with prescriptions between -4.00 and +1.00 (SE)
- Adverse effects: Per the Prescribing Information, the most common adverse reactions reported in clinical trials were headache, eye redness, and eye irritation.
- Dosage: Instill one drop in each eye once daily. A second dose (an additional drop in each eye) may be administered 3-6 hours after the first dose.
- Other notes: preserved with benzalkonium chloride (BAK)
Qlosi™ (pilocarpine 0.4%)
- FDA approved in 2023
- The long answer to “how does it work”: Essentially the same as Vuity, but it has a lower concentration of pilocarpine. This lower concentration may have an advantage. Recent data presented at Hawaiian Eye 2026 showed that pilocarpine 0.4% was more pupil selective than pilocarpine 2%, meaning that the lower concentration had less ciliary body response than pilocarpine 2% in the study. Translation? The lower concentration may reduce the negative effects we mentioned above: lens thickening and anterior displacement (which can cause a myopic shift and vitreoretinal traction that can lead to a retinal tear or detachment), as well as accomodative spasms that can cause browaches/headaches .
- Efficacy: Onset within 20 minutes, lasts up to 8 hours following the second application
- Who was included in the study? People age 45-64, with prescriptions between -4.50 and +2.00 (SE)
- Adverse effects: Per the Prescribing Information, the most common adverse reactions are instillation site pain and headaches.
- Dosage: 1 drop in each eye up to twice daily (2-3 hrs apart)
- Other notes: Preservative free
Vizz™ (aceclidine 1.44%)
- FDA approved in 2025
- The long answer to “how does it work”: Aceclidine is also a cholinergic agonist, so it has a very similar mechanism of action to pilocarpine. It has been used in glaucoma therapy in Europe for many years. The main difference is that aceclidine is “pupil-selective,” meaning that it effects the pupil size without having much of an effect on the ciliary body muscle. As we mentioned above, the benefit of that is less accommodative spasm and myopic shift, meaning less potential effect on distance vision and headaches. It also reduces the displacement of the lens, which is one of the mechanisms that increases the risk of retinal tear or detachment with miotics.
- Efficacy: Onset within 30 minutes, lasts up to 10 hours with once-daily dosing
- Who was included in the study? People age 45-75, with prescriptions between -4.00 and +1.00 (SE), inclusive of post-LASIK and post-cataract presbyopes
- Adverse effects: Per the Prescribing Information, the most common side effects are eye irritation, temporary dim or dark vision, headaches, and eye redness.
- Dosage: Instill one drop in each eye, wait 2 minutes and instill a second drop in each eye once daily from the same single-dose vial.
- Other notes: Preservative free
Yuvezzi™ (carbachol 2.75% and brimonidine tartrate 0.1%)
- FDA approved January 2026
- The long answer to “how does it work”: As mentioned earlier, Yuvezzi is the first and only dual-agent drop for presbyopia, combining two different drugs. Like pilocarpine, carbachol is a non-selective cholinergic agonist, meaning it activates acetylcholine receptors in the iris sphincter muscle and the ciliary body muscle. Brimonidine tartrate is an alpha-adrenergic agonist, meaning it activates or stimulates alpha adrenergic receptors. So it causes pupil constriction indirectly by blocking the contraction of the iris dilator muscle and relaxing the ciliary body muscle. It may also increase the bioavailability of carbachol, so it has a synergistic effect in combination. Brimonidine tartrate is an ingredient that’s been used in the eye world for a long time. It’s used in glaucoma therapy because of its ability to lower eye pressure by decreasing aqueous production and increasing drainage via the uveoscleral pathway. It’s also used at a lower concentration in the cosmetic eye-whitening drop Lumify because of its ability to constrict blood vessels.
- Efficacy: Onset within 30 minutes, lasts up to 10 hours
- Who was included in the study? People age 45-80, with virtually no distance prescription, inclusive of post-cataract presbyopes
- Adverse effects: Per the Prescribing Information, the most common side effects are headache, impaired vision and temporary eye pain or eye irritation.
- Dosage: Instill one drop in each eye once daily
- Other notes: Expected to be available in quarter 2 of 2026.
Who is a good candidate for these presbyopia drops?
These drops are designed for people who need help with near vision, generally folks age 40 and beyond. As you can see by the inclusion criteria used in the various studies, the ideal patient would not have a super high prescription; ideally low to moderate amounts of nearsightedness, low amounts of farsightedness, and low amounts of astigmatism. Post-surgical patients are also candidates, but because these drops can raise the risk of a retinal detachment, you’ll want to be screened by your optometrist first, especially if you had a high nearsighted/myopic Rx prior to your surgery.
What are the potential side effects?
The adverse effects for each drug are listed above, but the main warning that comes with all miotics is the risk for retinal detachment. Rare cases of retinal detachment have been reported with miotics, so it’s VERY important to get screened by your optometrist- yes, that means a DILATED eye exam- to make sure there are no retinal issues that would put you into a higher risk category.
| CliffsNotes: We now have 4 FDA-approved prescription eye drops to help with the age-related loss of near vision (presbyopia). All of them essentially work the same: they minimize the size of the pupil. This creates a pinhole effect, increasing depth of focus. There are side effects to be aware of, and not everyone is a good candidate, so make sure you see your optometrist for a full screening before considering a prescription. |