EMPOWER - Presbyopia in Practice: Matching Patients to Drops, Lenses, and Lifestyle

**Jacob Lang** (0:07)
Hi, everyone, I'm Jacob Lang. Welcome to another special episode of The MOD Pod. I'd like to welcome you back for the second installment of 2026, where we aim to help advance optometric knowledge and elevate our practices and our patient care. So thank you all for joining. I hope your year is off to a good start. I know spring is in the air, and spring is springing, as they say. So everyone's got this kind of new ambition and new life and everything's going good and turning green, at least up here in the Great White North. So I'm honored, as always, to be joined by a couple of close friends and colleagues here. We're going to talk about something I will never experience, presbyopia, forever young over here with the hairline to prove it. So we're going to talk about presbyopia today, honestly, something I am in the middle of, and it is obviously a priority, much more a priority to me than it was 10 years ago. And for anyone that's not, you just wait as the patients like to tell us.
So my guests that I am honored to be joined by Dr. Jackie Garlich and Dr. Mark Dunbar. I'm going to let you guys introduce yourselves as you can do a way better job than I can.

**Jackie Garlich** (1:26)
Hi, yeah, I'm Jackie Garlich. I have a private practice in Boston that sees a lot of primary care patients, but I have a dry eye specialty clinic as well. So I certainly see a lot of prospecific patients and looking forward to the discussion.

**Mark Dunbar** (1:41)
So I practice at the Basketball Moriah Institute in Miami, Florida where I've made a career of this for well over 30 years.
I also do comprehensive eye care, primary eye care. I'm known as more of a retina guy, but that's how I started my career, but it's really kind of comprehensive. Diabetes, cataracts, presbyopia, deciding higher ads, progressives. I even do a little bit of contact lenses. So I know we're going to get into that discussion, which I'm a novice at, but I'll look forward to having a discussion and hearing what your thoughts are.

**Jacob Lang** (2:17)
Nah, you're novice is another man's pro. So let's get into it. Let's talk about presbyopia, right? This inevitable change that's going to happen to our eyes. We won't spend a lot of time talking about this, right? But somewhere between 40 and 50, your arms are going to get a little longer. You're not going to be able to focus as well as you used to. And we now have this new kind of space in optometry focused around pharmaceutical options for treating this.
We have drops that help treat presbyopia. How do they work, Jackie? How do you explain that? How do they, what's their mechanism of action? We'll classify all of them kind of together.

**Jackie Garlich** (2:57)
Yeah, I usually, when I'm talking about this to the patient, I just make it very simple. I just say this works by really constricting your pupil and increasing your depth of focus. This is how this is working to help you see up close. I don't go into too much of the details of that, but I think that usually is enough from a patient perspective.

**Mark Dunbar** (3:17)
I don't make it too complicated exactly as Jackie described it.

**Jacob Lang** (3:20)
Yeah, so really we have myotics right now. And so when we're talking about pharmacirgals for presbyopia, we're talking about meiosis. Yeah, I always kind of describe it as my dilated patient is kind of staring at me with their big pupils. Like this does the opposite, right? We dilate your eyes to check your health and it makes your vision worse, makes you sensitive to light. We're gonna, you know, this medications work in the opposite way. They make your pupils small and that helps boost the up close vision. So I always use that analogy because that's something I think most people have experienced much more dilation than meiosis. So something to think about and gives us kind of a reference point to discuss about. So this started, this kind of whole space started recently, right? 2021, VioD was launched. And then the second drop, Closie, was launched in 2023, both Pylacarpine based drops.
Explain your experience with those, Mark, and kind of what you've seen and kind of that evolution in the early 20s with our first couple of medications in this presbyopic space.

**Mark Dunbar** (4:28)
So I, you know, grew up with Pylacarpine, right? I mean, obviously, we learned about it in our pharmacology classes. You know, we didn't have the Prostaglandins, we, of course, had Timalol, we didn't have some of the glaucoma drugs that we have today. So Pylacarpine was a pretty usual medication that we used. And so, you know, we didn't give it much thought. Obviously, we were all taught the risks of retinal detachments and some of the issues related to Pylacarpine. But, you know, quite honestly, I don't think, you know, I really ever saw it in clinical practice, mainly because these were elderly patients, you know, when they were on it, they were on it for life. It was a four times a day drop.