Anti-presbyopia drops - are we there yet?

Common Qlosi side effects are painful or sore eyes and headaches, affecting 5–8% patients in trials. Blurred vision occurred in 2–5% of patients. However, most side effects were mild, short lasting and resolved without further action. Warnings associated with Qlosi, which are common to miotics generally, include blurred vision, particularly at night or in low light conditions, and a potential risk of retinal detachment. Examination of the retina is advisable in all patients before using miotics, but those with high myopia or other risks of retinal detachment should avoid using them.

Is Vizz the biz?

Vizz is the new kid on the block, seemingly wiping all previous attempts at anti-presbyopia drops off the table, at least for the moment. Manufactured by pharmaceutical company LENZ, it received FDA approval in September 2025 based on the results of three clinical studies reviewing efficacy and safety.

Vizz (aceclidine hydrochloride 1.44%) ophthalmic solution is used once daily, one drop in each eye. The studies showed maximum effect after 30 minutes and lasting up to 10 hours. Aceclidine hydrochloride is a cholinergic agonist that works by stimulating pupil constriction with relatively minimal effect on the ciliary muscle, resulting in a pinhole effect supposedly without accommodative spasm. Like pilocarpine, it has historically been used for treatment of glaucoma. Systemic side effects are rare but can occur with overdose and include increased salivation, sweating, nausea and abdominal cramps. Less common is a significant drop in blood pressure, which can lead to dizziness or fainting, or an allergic reaction, such as a rash, itching, swelling or difficulty breathing.

Vizz is presented in a preservative-free single-dose vial. It is not yet available in New Zealand or Australia, although neither is Qlosi, which can be ordered online by prescription in Australia through certain pharmacies. Professional samples of Vizz are being distributed to eyecare professionals and it’s now available in retail pharmacies in the US.

More options are pending, such as Brimochol PF (Tenpoint Therapeutics), which is carbachol 2.75% and brimonidine tartrate 0.1%, once daily and is preservative free. An FDA decision is expected in January 2026. Meanwhile, in June this year, Opus Genetics/Viatris announced positive top-line results from Vega-3, the second pivotal phase 3 trial evaluating MR-141 phentolamine 0.75%, its once-daily preservative-free drop.

All FDA studies leading to the approval of anti-presbyopia eye drops must demonstrate that the percentage of patients using the study drug who achieve a ≥15-letters (three lines) improvement in binocular near vision, without losing ≥5 letters (one line) of distance vision, is statistically significantly higher than the percentage of patients in the control group. That may determine the statistical evidence of a successful trial, but what about the functional measures, such as fatigue or reading speed and accuracy? Fortunately, double-blind studies are not an option for comparison!

As with any drug, reactions will vary from one patient to another. If the pupil is too small, it may not allow enough light in for good vision. If too large, the pinhole effect of extended depth of focus will not be achieved. Patients with the highest likelihood of success are emmetropic early presbyopes, pseudophakes and long-term contact lens wearers who do not tolerate monovision or multifocal contact lenses. Older low myopes may also benefit.

Is Vizz the magic drop we’ve been holding our breath for – soon to be available via door-to-door delivery, like weightloss drugs or Uber Eats – or just good marketing hype? Until we can find out for ourselves, I’m sure our US colleagues will keep us informed!

Naomi Meltzer is an optometrist who runs an independent practice specialising in low-vision consultancy. She is a regular contributor to NZ Optics.