Comments on “the effect of 2% pilocarpine on depth of field in different time intervals among presbyopic subjects”

Dear Editor, I recently read the article titled “The Effect of 2% Pilocarpine on Depth of Field in Different Time Intervals Among Presbyopic Subjects” by Tripathi A et al.[1] with great interest. This study provides valuable insights into the pharmacologic management of presbyopia using pupillary miotics. However, I would like to highlight certain limitations and suggest improvements that could enhance the robustness of the findings and their applicability. The study’s methodology for measuring baseline depth of field (DOFi) does not include sufficient comparison with age-matched controls not using pilocarpine. As DOFi can vary based on environmental and physiological factors, the inclusion of a control group would have better contextualized the outcomes. Additionally, the subjective method of assessing DOFi, where participants indicate when they can or cannot see the chart clearly, introduces potential observer bias. Prior studies have shown that objective methods, such as wavefront aberrometry, offer more precise measurements and could have strengthened the study’s reliability.[2,3] The study attributes changes in DOFi primarily to pupil miosis without fully exploring the potential contribution of pilocarpine-induced accommodation. Research has shown that pilocarpine affects both pupil size and accommodative amplitude.[4] Objective accommodative response measurements, such as those obtained through autorefractometry or optical coherence tomography, could have provided a clearer understanding of the mechanisms involved. Furthermore, the study evaluated DOFi changes only within 45 min of pilocarpine instillation. While these results are insightful, the absence of longer-term follow-up limits the understanding of sustained efficacy and potential rebound effects. Investigations into the duration of pilocarpine’s effects are essential for assessing its practical clinical use. The study briefly mentions that some participants experienced mild to moderate headaches but lacks detailed data on their incidence or severity. Comprehensive documentation of adverse effects, as seen in related studies, is essential for a thorough evaluation of pilocarpine’s safety in presbyopia management.[5] In conclusion, while this study highlights the potential of pilocarpine in extending DOFi in presbyopes, addressing the aforementioned limitations would significantly enhance the scientific rigor and clinical relevance of the findings. These considerations could serve as a foundation for future research to advance pharmacological treatments for presbyopia. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.