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James A Katz,1 Paul M Karpecki,2 Alexandra Dorca,3 Sima Chiva-Razavi,4 Heather Floyd,4 Elizabeth Barnes,4 Mark Wuttke,4 Eric Donnenfeld5 1The Midwest Center for Sight, Des Plaines, IL, USA; 2Kentucky Eye Institute, Lexington, KY, USA; 3Favoris AG, Basel, Switzerland; 4Novartis Pharma AG, Basel, Switzerland; 5Ophthalmic Consultants of Long Island, Garden City, NY, USACorrespondence: Eric DonnenfeldOphthalmic Consultants of Long Island, 711 Stewart Avenue, Suite 160, Garden City, NY, 11530, USAEmail ericdonnenfeld@gmail.comAbstract: Presbyopia is a common age-related vision disorder characterized by a progressive inability to focus on near objects. If uncorrected or under-corrected, presbyopia can significantly impact patients’ quality of life. Presbyopia represents an area of considerable unmet need due to its rising prevalence worldwide as the population ages, the high proportion of under-treated individuals in some parts of the world, and the limitations of currently available corrective methods. Progressive or bifocal spectacles are associated with peripheral blur, a restricted visual field and impaired depth perception, which have been linked to an increased risk of falls in the elderly. Contact lens options can be difficult to maintain due to the development of age-related dry eye symptoms and reduced manual dexterity. Other corrective methods involve surgical interventions that modify the optics of the cornea, replace the crystalline lens, or attempt to restore active accommodation. While patients undergoing surgery report satisfactory outcomes post-operatively, many of them eventually require reading glasses. Non-invasive therapies with novel mechanisms of action are currently being investigated; these include miotic agents and UNR844, a lipoic acid choline ester. In this narrative review, available evidence on presbyopia prevalence, quality of life impact and risk factors are described, with a focus on observational studies in non-clinical settings. The diagnosis pathway and patient journey in presbyopia are outlined, and various treatment options are analyzed. The data reviewed herein reveals significant gaps in the provision of vision correction for this common condition, with a paucity of effective, non-invasive treatment options broadly accessible to presbyopic individuals.Keywords: presbyopia, epidemiology, patient characterization, vision correction, pharmacological therapies

Jay S Pepose,1,2 Paul J Hartman,3 Harvey B DuBiner,4 Marc A Abrams,5 Robert J Smyth-Medina,6 Sayoko E Moroi,7 Alan R Meyer,8 Mina P Sooch,8 Reda M Jaber,8 Konstantinos Charizanis,8 Seth A Klapman,8 Arin T Amin,8 Jonah E Yousif,8 Eliot S Lazar,9 Paul M Karpecki,10 Charles B Slonim,11 Marguerite B McDonald12 1Pepose Vision Institute, St. Louis, MO, USA; 2Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, MO, USA; 3Department of Ophthalmology, University of Rochester, Rochester, NY, USA; 4Clayton Eye Center, Morrow, GA, USA; 5Case Western Reserve University, Cleveland, OH, USA; 6North Valley Eye Medical Group, Mission Hills, CA, USA; 7The Ohio State University Wexner Medical Center, Columbus, OH, USA; 8Ocuphire Pharma Inc, Farmington Hills, MI, USA; 9elCON Medical, Buffalo, NY, USA; 10Kentucky College of Optometry, University of Pikeville, Pikeville, KY, USA; 11Oculos Development Services, LLC, Tampa, FL, USA; 12Department of Ophthalmology, New York University Langone Medical Center, New York, NY, USACorrespondence: Konstantinos CharizanisOcuphire Pharma, Inc., 37000 Grand River Ave, Farmington, MI 48335, USATel +1 (352) 328 9117Email kcharizanis@ocuphire.comPurpose: Phentolamine mesylate ophthalmic solution (PMOS), applied to the eye topically, was shown previously to have beneficial effects in patients with dim light vision disturbances (DLD), including decreased pupil diameter (PD), improved best-corrected distance visual acuity (BCDVA), as well as lower intraocular pressure (IOP). The ORION-1 trial evaluated the long-term safety and efficacy of PMOS in a glaucomatous, presbyopic population.Patients and Methods: In this randomized, double-masked, multi-center, placebo-controlled, multiple-dose Phase 2b trial, 39 patients with elevated IOP were randomized to receive one evening dose of study medication or placebo for 14 days. The primary outcome measure was mean change in diurnal IOP, and the key secondary outcome measures included changes in PD, distance-corrected near visual acuity (DCNVA), and conjunctival hyperemia.Results: Use of 1% PMOS did not lead to a statistically significant decrease in diurnal IOP compared to placebo (P = 0.89) but trended toward a greater decrease in patients with lower IOP baselines. PMOS produced a statistically significant mean 20% PD reduction under both photopic and mesopic conditions that was sustained for 36 hours post-dosing. A statistically significant number of patients with PMOS compared to placebo demonstrated ≥ 1 line of improvement in photopic DCNVA at day 8 (P = 0.0018), day 15 (P = 0.0072), and day 16 (P = 0.0163), with a trend for 2- and 3-line improvements at all time points. There was no statistical difference in conjunctival hyperemia compared to placebo.Conclusion: Although mean IOP was not lowered significantly, daily evening dosing of 1% PMOS was found to be well tolerated with no daytime conjunctival redness and demonstrated improvement in DCNVA with sustained PD reduction in a glaucomatous and presbyopic population. Smaller pupil size can have beneficial effects in improving symptoms of presbyopia and DLD, which will be the focus of further studies.Keywords: IOP, presbyopia, night vision disturbances, dim light vision disturbances, pupil diameter, ORION-1