Comments on “Enhancing presbyopia treatment: A comparative study of 1% Pilocarpine monotherapy versus combination with 0.09% bromfenac”

Dear Editor, We were fascinated by Jain et al.’s study that compared the use of 1% pilocarpine alone with its combination with 0.09% bromfenac for the treatment of presbyopia.[1] Although the study highlights a novel therapy approach, many methodological and clinical issues require more discussion. The phrase “new-onset presbyopia” is highly contentious. Early presbyopia, also known as pre-presbyopia, frequently emerges between the ages of 35 and 45 years. The condition is more diverse when phakic individuals between the ages of 40 and 55 years are included. Individuals over 50 years often have presbyopia and may have reduced accommodative reserve abilities.[2] The results would have been strengthened by subgroup analysis, and this wide age range could affect how well a treatment works. Despite the use of randomization, there was a statistically significant difference in near visual acuity at the beginning of the trial (P = 0.005), which may make it difficult to compare the results. The inclusion criteria placed a strong emphasis on near visual acuity, but they did not specify standardized distance visual acuity thresholds, which are crucial considering the observed reduction in distant vision. It is more challenging to assess long-term safety within the 8-week follow-up period, particularly when retinal problems arise following miotic therapy.[3] The results show that the combination group had better near visual acuity outcomes (78.6% reaching N6 compared to 44.1%). This benefit, however, comes with a small loss of distance visual acuity. This is probably due to a spasm that makes the eye more flexible, which is caused by pilocarpine.[3,4] The absence of a significant difference in ≥3-line improvement and comparable patient satisfaction, coupled with statistically significant enhancements in accommodative parameters, indicates a divergence between objective and subjective outcomes. Pilocarpine enhances near vision by inducing miosis and ciliary muscle contraction; nevertheless, it may cause transient adverse effects such as headache, brow pain, and impaired night vision.[3] Using it for a long time may cause more traction in the vitreoretinal area and put more stress on the system that helps you focus.[4] Bromfenac is a nonsteroidal anti-inflammatory drug that may help with eye pain and make it easier to tolerate; nevertheless, using it for a long time can hurt the corneal epithelium and slow down healing.[5] Retinal safety continues to be an issue with extended miotic therapy, which is of paramount importance. Pilocarpine has been associated with heightened vitreoretinal traction and a rare occurrence of retinal detachment, particularly in individuals predisposed to these conditions,[3] notwithstanding the absence of retinal events documented in this study. This underscores the imperative for prolonged monitoring and meticulous patient selection. In conclusion, it is important to consider the baseline imbalances, the uneven age range of participants, and the short follow-up time when deciding which option is better, even though the combination of pilocarpine and bromfenac looks promising. Extended trials incorporating age-specific analysis and thorough retinal evaluations are essential to ascertain long-term safety and efficacy. Author contributors Sachitanand Singh: Concepts, Design, Literature, Data acquisition, Data analysis search, Manuscript preparation, Manuscript review; Ashith Tripathi: Design, Literature search, Statistical analysis, Manuscript editing, Manuscript review, Guarantor. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.