By Dr. Cameron McCrodan, OD, FCOVD – Opto-Mization Optometry & Vision Therapy, Victoria & Nanaimo, BC
Why I Approach Presbyopia Drops with Both Excitement and Caution
Before I became an optometrist, I studied engineering. That background means I’m wired to think in systems and trade-offs. Change one component of a system and the rest responds. Your eyes and the way your brain uses them are no different.
That’s why when new treatments arrive—like VIZZ™ (aceclidine 1.44%), the most recently FDA-approved presbyopia eye drop (approval letter dated July 31, 2025: FDA letter; company announcement: LENZ press release)—my reaction is always mixed. I’m excited because it gives us another tool. I’m cautious because in vision, just like in engineering, there’s no free lunch. If you change one part (pupil size), you should expect impacts elsewhere (light, contrast, binocular balance).
Presbyopia is the gradual loss of near focus that shows up for almost everyone after 40. Traditional solutions include readers, bifocals, progressives, or contact-lens strategies. Pharmacologic options take a different path: they make the pupil smaller to create a “pinhole effect,” which reduces blur from optical imperfections and extends depth of focus so near objects come into view more easily. That mechanism is described in FDA-approved labeling for pilocarpine-based products and in the aceclidine label for VIZZ: VUITY® (pilocarpine 1.25%) (first approval, 2021), QLOSI™ (pilocarpine 0.4%) (second approval, 2023), and VIZZ™ (aceclidine 1.44%) (third approval, 2025).
What Is Presbyopia?
Presbyopia is driven by age-related changes in the crystalline lens. As the lens stiffens, the eye’s ability to change focus for near tasks declines. The real-world symptom is classic: you hold your phone farther, then a little farther still; restaurant menus and labels blur at arm’s length. Patients often self-manage with inexpensive readers; others move to progressives or task-specific lenses after an exam. Pharmacologic therapy doesn’t “rejuvenate” the lens; it changes the optics—primarily by constricting the pupil to increase depth of focus. The approved labels and clinical summaries describe this approach for VUITY, QLOSI, and VIZZ.
How Presbyopia Drops Work
The pinhole effect (what a smaller pupil actually does)
A smaller aperture cuts peripheral rays and reduces the impact of optical aberrations (imperfections in the eye’s optics). That “pinhole effect” expands depth of focus so near targets look sharper without changing the eye’s prescription. In practice, that can be the difference between needing readers for every label and being able to check your phone or a menu comfortably after you instill a drop. This is the intended mechanism behind miotic presbyopia therapies as reflected in the pharmacology and clinical-studies sections of the FDA labels for pilocarpine 1.25% (VUITY), pilocarpine 0.4% (QLOSI), and aceclidine 1.44% (VIZZ).
Discover whether presbyopia drops are right for you. Opto-Mization in Victoria & Nanaimo offers expert assessments to ensure comfort, clarity, and healthy binocular vision.
The FDA-approved options (what the labels say)
VUITY® (pilocarpine HCl 1.25%) was the first FDA-approved presbyopia drop (2021). The label indicates one drop in each eye once daily and summarizes pivotal Phase 3 outcomes (GEMINI-1 and GEMINI-2), where a significantly higher proportion of treated participants achieved clinically meaningful near-vision gains at Day 30 vs vehicle. Label: VUITY FDA PI.
QLOSI™ (pilocarpine HCl 0.4%) followed in 2023. The label allows dosing up to twice daily using single-use vials: one drop in each eye and, if needed, a second instillation 2–3 hours later. The clinical data describe onset as early as ~20 minutes and effect up to 8 hours after the second dose. Label: QLOSI FDA PI.
VIZZ™ (aceclidine 1.44%) is the newest option, FDA-approved July 31, 2025 (see approval letter). The label describes once-daily administration as one drop in each eye, wait 2 minutes, then a second drop in each eye from the same single-dose vial. Clinical sections assess outcomes from 30 minutes through 10 hours post-dose; the company’s announcement describes efficacy “up to 10 hours.” Label: VIZZ FDA PI; press release: LENZ.
Benefits Patients Report
Clinical trial outcomes (what was measured)
VUITY (GEMINI-1/-2): At Day 30, significantly more treated participants achieved ≥3 lines of improvement in mesopic, high-contrast binocular distance-corrected near visual acuity (DCNVA) at Hour 3 versus vehicle (e.g., 31% vs 8% in GEMINI-1; 26% vs 11% in GEMINI-2, as summarized in the label’s clinical-studies section). Source: VUITY FDA PI.
QLOSI (NEAR-1/-2): The label describes onset from about 20 minutes and duration up to 8 hours after the second daily instillation, with efficacy endpoints consistent with improved near vision vs vehicle. Source: QLOSI FDA PI.
VIZZ (CLARITY-1/-2/-3): The label outlines assessments beginning 30 minutes after dosing, with timepoints through 10 hours post-dose. The company’s FDA-approval announcement states near-vision improvement up to 10 hours on once-daily, two-instillation dosing. Sources: VIZZ FDA PI; LENZ press release.
Real-world convenience (where people notice the difference)
When these drops work well, they’re genuinely helpful for common tasks: reading a menu in a bright café, checking a phone, moving between a laptop and across-the-room conversations. They’re on-demand—no surgery and no permanent change. If a dose doesn’t suit your plans (for instance, you’re driving at night), you can simply skip it and use your usual glasses. In clinic, many patients like having that flexibility alongside their primary optical correction.
The Trade-Offs of Small Pupils
Dim vision and night-driving cautions
A smaller pupil admits less light. In good lighting, this is fine. In low light, it can make the visual world feel dimmer. Every FDA label here—VUITY, QLOSI, and VIZZ—advises patients that temporary dim or dark vision may occur and to avoid driving or operating machinery if vision is not clear, with explicit caution for night driving or hazardous tasks in poor illumination. This is label language, not interpretation.
Why chart vision ≠ real-world contrast
Eye charts are high contrast: black letters on bright white. Night streets in rain are not. Subtle curb edges, grey-on-grey labels, faint lane markings—all are lower contrast. When less light reaches the retina, these can be harder to detect even if your high-contrast acuity looks good. The labels don’t use the term “contrast sensitivity,” but their low-light cautions speak directly to this real-world issue.
Common side effects you should plan for
VUITY: The most common adverse reactions (≥5%) include headache and conjunctival hyperemia, with other ocular effects like blurred vision or irritation reported in smaller percentages. Source: VUITY FDA PI.
QLOSI: The most common treatment-related reactions noted in the label include instillation-site pain and headache (≥5%), with blurred vision reported in a smaller proportion. Source: QLOSI FDA PI.
VIZZ: The press announcement quantifies that the most common reactions were instillation-site irritation (20%), dim vision (16%), and headache (13%), with conjunctival/ocular hyperemia in >5%; the label aligns on the reaction types and cautions. Sources: VIZZ FDA PI; LENZ press release.
Retinal safety warnings (rare but important)
All three labels include a warning that rare cases of retinal tear or detachment have been reported with miotics and instruct patients to seek immediate care for sudden flashes, floaters, or a curtain of vision. If you’re highly myopic or have known retinal issues, your doctor may recommend a dilated retinal evaluation before long-term use—this is prudent clinical practice alongside label counseling. Sources: VUITY FDA PI; QLOSI FDA PI; VIZZ FDA PI.
The binocular-vision factor (why some people feel “off”)
Your brain must fuse two images into one. Smaller pupils reduce retinal illuminance, which can increase the effort required for binocular teaming, especially later in the day or in low light. In people with fragile binocular control, that can show up as eye strain, headaches, intermittent double vision, fluctuating clarity, motion sensitivity, or reading difficulty even if chart acuity looks fine. Labels won’t list that because it’s task- and person-dependent, but the universal low-light cautions are precisely why we assess function, not just acuity.
One more point on the pinhole effect: by trimming peripheral light, it also trims peripheral spatial information. That reduction in retinal illuminance plus less peripheral input can destabilize vergence and stereopsis in everyday tasks. Many people will “see clearly” on a chart yet need more cognitive effort to keep vision single and comfortable—showing up as slower reading, reduced comprehension over time, headaches, and end-of-day fatigue.
For that reason, for most adults—especially those who read for long stretches, switch rapidly between distances, or work in mixed/low lighting—the trade-offs in depth perception, coordination, fatigue, and sustained focus are often not worth it as a primary strategy. We generally recommend a properly prescribed, binocularly optimized lens solution as the baseline, using a miotic drop only as an occasional adjunct when the situation truly calls for it.
Patient Scenarios (Where These Trade-Offs Show Up)
The bright office worker
If you spend most of your day in well-lit offices flipping between laptop and meetings, a miotic drop can be a convenient “reader-alternative” for several hours. QLOSI allows a second instillation after 2–3 hours to extend coverage (up to twice daily). VIZZ is once daily with two instillations separated by 2 minutes and assessments reported through 10 hours post-dose; the company describes up to 10 hours of benefit. Plan first-ever doses on days without late-evening driving.
The night driver
If you frequently drive at night or on dark rural roads, pay close attention to the low-light warnings in VUITY, QLOSI, and VIZZ. A smaller pupil can make dim scenes feel darker and reduce the visibility of faint lane edges. If you trial drops, do it well before any night driving and only continue once you know night vision remains clear for you.
The avid reader
If you love long reading sessions in the evening, keep a good task light nearby. Miotics can help near clarity, but they also reduce retinal illuminance. Good lighting minimizes that trade-off. On days you plan multi-hour reading, some patients prefer optical solutions (task lenses or progressives) and use drops for daytime convenience.
The post-concussion or motion-sensitive patient
If you have a history of concussion, dizziness, or motion sensitivity, changes in peripheral input and retinal illuminance may be more noticeable. We’ll emphasize functional-vision testing before deciding. Some patients do fine with careful timing and lighting; others prefer lens-based approaches and therapy first.
Comparing the FDA-Approved Options (What to Expect, Practically)
VUITY® (pilocarpine 1.25%)
Indication: treatment of presbyopia in adults.
Dosing: one drop in each eye once daily; separate other topicals by ≥5 minutes; remove contact lenses before dosing and wait ~10 minutes to reinsert.
Warnings and precautions: may cause temporary blurred, dim, or dark vision; use caution with night driving or hazardous tasks in poor illumination; rare reports of retinal tear/detachment with miotics; caution in patients with active iritis.
Common adverse reactions: headache, conjunctival hyperemia (≥5%); smaller percentages for blurred vision, eye irritation, etc.
Source: VUITY FDA PI.
QLOSI™ (pilocarpine 0.4%)
Indication: treatment of presbyopia in adults.
Dosing: one drop in each eye; may repeat a second time 2–3 hours later; up to twice daily; single-patient-use vials; separate other topicals by ≥5 minutes; remove lenses and wait ~10 minutes before reinsertion.
Warnings and precautions: similar to VUITY—temporary dim/dark vision; night-driving caution; rare reports of retinal detachment; avoid with active iritis.
Common adverse reactions: instillation-site pain, headache (≥5%); blurred vision in a smaller proportion.
Onset/duration: onset ~20 minutes; effect up to 8 hours after the second daily dose.
Source: QLOSI FDA PI.
VIZZ™ (aceclidine 1.44%)
Indication: treatment of presbyopia in adults.
Dosing: one drop in each eye, wait 2 minutes, then a second drop in each eye once daily (from the same single-dose vial); separate other topicals by ≥5 minutes; remove lenses and wait ~10 minutes before reinsertion.
Mechanism note: the company and label pharmacology describe VIZZ as a predominantly pupil-selective miotic with minimal ciliary muscle stimulation. This design aims to reduce accommodative spasm and the likelihood of a clinically meaningful myopic shift, though individual responses vary.
Warnings and precautions: may cause temporary blurred, dim, or dark vision; use caution with night driving; rare reports of retinal tear/detachment with miotics; avoid with active iritis.
Common adverse reactions: instillation-site irritation (20%), dim vision (16%), headache (13%); conjunctival/ocular hyperemia >5%; in trials most reactions were mild and self-resolving.
Onset/duration: label assessments begin 30 minutes post-dose and extend to 10 hours; the company describes efficacy up to 10 hours.
Sources: VIZZ FDA PI; FDA approval letter; LENZ press release.
Alternatives and Future Directions
Optical solutions that still matter
Even with effective drops, optical tools remain essential. Task-specific lenses for your work distance, well-fit progressives, or multifocal contact lenses can deliver predictable, all-day function without the low-light trade-offs of miosis. We often combine tools: a progressive for long reading sessions and a drop for daytime flexibility.
Vision therapy for the binocular bottleneck
If your challenge is binocular control (eye teaming, fixation, accommodative flexibility), pharmacology won’t solve that bottleneck. A targeted vision-therapy plan can build stability and endurance so you tolerate small-pupil optics better—or sometimes no longer need them for certain tasks.
Non-miotic research (what’s being explored)
A peer-reviewed case series (n=363) by Vejarano and colleagues evaluated a compounded multi-agent formula (“FOV Tears”: pilocarpine 0.247%, phenylephrine 0.78%, plus other components). They reported mean binocular near-vision improvement approaching two logMAR lines, with 91.5% improving by ≥1 line; the improvement was not correlated with pupil change on regression analysis. Scotopic pupils decreased by ~1 mm, photopic change was negligible, and the mean refractive shift was small (−0.17 D). This is not FDA-approved and was a case-series design (no control group), but it suggests future drops may provide near-vision gains with minimal pupil impact. Study: Ophthalmology and Therapy (2023).
Frequently Asked Questions
Do these drops replace my readers?
Sometimes. For some patients, a dose covers common near tasks for several hours. Others still prefer readers for long evening sessions or low-light work. It’s normal to use both.
Can I use them every day?
Follow the label and your doctor’s advice. VUITY is once daily. QLOSI allows up to two instillations per day separated by 2–3 hours. VIZZ is once daily with two instillations separated by 2 minutes.
Will they blur my distance vision?
In good lighting, most patients keep comfortable distance clarity, but dim settings can feel darker and make details less distinct. All labels instruct patients to avoid driving or hazardous tasks if vision isn’t clear and to use caution with night driving.
What about contact lenses?
All three labels instruct you to remove lenses before dosing and wait ~10 minutes before reinsertion. See: VUITY PI, QLOSI PI, VIZZ PI.
What symptoms should I never ignore?
Flashes, new floaters, or a curtain in vision—seek immediate care. Each label includes a warning about rare retinal tear/detachment with miotics and advises urgent evaluation if these symptoms occur. See: VUITY PI, QLOSI PI, VIZZ PI.
How We Decide Together at Opto-Mization
I approach this like an engineer. We start with your visual life: bright office or dim shop? Daytime errands or frequent night driving? Then we run a functional-vision assessment—how your eyes team, focus, and track across lighting and task conditions. If drops look like a fit, we trial a dose in-office and then have you walk, read, and shift focus between near and far. We plan first uses on days without critical night driving, consistent with the labels’ low-light cautions. If you notice dimness or headaches, we adjust timing, discuss QLOSI’s two-dose approach or VIZZ’s longer coverage, and consider task-specific lenses or vision therapy when binocular control is the bottleneck. The goal isn’t to push drops or lenses—it’s to engineer a plan around your eyes, your brain, and your life.
Bottom Line
Presbyopia drops are real options, not hype. VUITY and QLOSI use pilocarpine with different dosing logistics; the newest, VIZZ, uses aceclidine and is designed as a predominantly pupil-selective miotic with once-daily, two-instillation dosing and evidence through 10 hours post-dose (company-reported “up to 10 hours” efficacy). These medications are on-demand tools that can improve near vision without surgery. They also make pupils small—and that has consequences in low light and for some people’s binocular balance. With a functional-vision approach, we can help you enjoy the benefits and steer around the pitfalls.
References
VUITY® (pilocarpine HCl 1.25%) — FDA Prescribing Information: https://www.accessdata.fda.gov/drugsatfda_docs/label/2023/214028Orig1s002lbl.pdf
QLOSI™ (pilocarpine HCl 0.4%) — FDA Prescribing Information: https://www.accessdata.fda.gov/drugsatfda_docs/label/2023/217836s000lbl.pdf
VIZZ™ (aceclidine 1.44%) — FDA Prescribing Information: https://www.accessdata.fda.gov/drugsatfda_docs/label/2025/218585s000lbl.pdf
FDA Approval Letter for VIZZ (July 31, 2025): https://www.accessdata.fda.gov/drugsatfda_docs/appletter/2025/218585Orig1s000ltr.pdf
LENZ Therapeutics Press Release (July 31, 2025): https://ir.lenz-tx.com/news-events/press-releases/detail/39/lenz-therapeutics-announces-us-fda-approval-of-vizz-for-the-treatment-of-presbyopia
Vejarano F, Alió J, Iribarren R, Lança C. Non-Miotic Improvement in Binocular Near Vision with a Topical Compound Formula for Presbyopia Correction. Ophthalmology and Therapy. 2023. https://link.springer.com/article/10.1007/s40123-023-00648-6
