A retrospective study of 766 patients presented on September 14 at the 43^rd Congress of the European Society of Cataract and Refractive Surgeons (ESCRS) [1], found that the majority could read an extra two, three or more lines on the eye chart used for testing near visual acuity (the Jaeger chart) after using specially formulated eye drops. This improvement was sustained for up to two years.

Dr Giovanna Benozzi, director of the Center for Advanced Research for Presbyopia, in Buenos Aires, Argentina, said: “We conducted this research due to the significant unmet medical need in presbyopia management. Current solutions such as reading glasses or surgical interventions have limitations, including inconvenience, social discomfort, and potential risks or complications. There is a group of presbyopia patients who have limited options besides spectacles, and who are not candidates for surgery; these are our primary focus of interest. We sought to provide robust clinical evidence supporting an innovative pharmacological solution to offer patients a non-invasive, convenient and effective alternative.”

The eye drops, developed by Dr Benozzi’s father, the late Dr Jorge Benozzi of the same centre, contain a combination of two active agents: pilocarpine, a drug that constricts the pupils and contracts the ciliary muscle, which is a muscle controlling the eye’s accommodation for seeing objects at varying distances, and diclofenac, a non-steroidal anti-inflammatory drug (NSAID) that reduces inflammation and the discomfort that pilocarpine often causes.

Patients administered the eye drops twice a day, usually on waking and again approximately six hours later, with an optional third dose if symptoms recurred or additional visual comfort was needed. The group of patients (373 women and 393 men, with an average age of 55) were divided into three groups to receive one of three eye drop formulations. Each formulation had a fixed dose of diclofenac but concentrations of pilocarpine were 1%, 2% and 3%.

The researchers assessed the improvement in how well patients could read the Jaeger chart without reading glasses (uncorrected near visual acuity) one hour after the first administration of the drops, and they followed up the patients for two years.

Dr Benozzi told the Congress: “Our most significant result showed rapid and sustained improvements in near vision for all three concentrations. One hour after having the first drops, patients had an average improvement of 3.45 Jaeger lines. The treatment also improved focus at all distances.

“Impressively, 99% of 148 patients in the 1% pilocarpine group reached optimal near vision and were able to read two or more extra lines. Approximately 83% of all patients maintained good functional near vision at 12 months. Importantly, no significant adverse events like increased intraocular pressure or retinal detachment were observed.”

In the 2% group, 69% of 248 patients were able to read three or more extra lines on the Jaeger chart, and in the 3% group, 84% of 370 patients could read three or more extra lines.

The improvement in the patients’ vision was sustained for up to two years, with a median duration of 434 days. Adverse side effects were mild, with the most common being temporary dim vision, which occurred in 32% of cases, irritation when the drops were instilled (3.7%) and headache (3.8%). No patients discontinued the treatment.

Common adverse side effects of pilocarpine can also include eye redness, watery eyes, blurred vision, dim or dark vision, sensitivity to light or problems changing focus between objects, seeing flashes of light or “floaters” in vision, and, in rare cases, detached retinas.

Dr Benozzi continued: “Nearly all patients experienced positive improvements in near visual acuity, although the magnitude of the improvement depended on the status of their vision before treatment at baseline. Our study revealed that optimal pilocarpine concentrations could be individualized depending on the baseline severity of presbyopia as assessed by the initial Jaeger scores. Patients with less severe presbyopia responded best to 1% concentrations, while those with more advanced presbyopia required higher 2% or 3% concentrations to achieve significant visual improvement.”

She concluded: “These results suggest this combination therapy offers a safe, effective, and well-tolerated alternative to traditional presbyopia management. It significantly reduces dependence on reading glasses, providing a convenient, non-invasive option for patients, although these eye drops may not eliminate the need for glasses in all individuals.

“Importantly, this treatment is not intended to replace surgical interventions, but rather to serve as a valuable solution for patients who need safe, effective, and personalised alternatives and seek freedom from the inconvenience of eyewear. Eye care professionals now have an evidence-based pharmacological option that expands the spectrum of presbyopia care beyond glasses and surgery.”

Besides the group of patients in this study, Dr Benozzi has other patients who have received the treatment for more than ten years. Dr Benozzi plans further research to measure improvements in patients’ quality of life, and to explore the underlying physiological mechanisms of the eye drops.

Strengths of the study include the large number of patients included and the long follow-up time. It is the first systematic evaluation comparing three different pilocarpine concentrations in combination with diclofenac. A limitation is that it is a retrospective, single-centre study, which could limit the generalizability of the findings and introduce selection bias.

ESCRS President-Elect, Professor Burkhard Dick, chair of the ophthalmology department at the University Eye Hospital Bochum, Germany, was not involved in the research. He commented: “While surgery for age-related near vision loss has advanced, some patients are not candidates. The single-centre retrospective study by Dr Benozzi suggests that eye drops containing pilocarpine and diclofenac may improve near vision for up to two years, but the limited design means the results may not apply to everyone. Long-term pilocarpine use can sometimes cause side effects such as reduced night vision, dimmer vision in low light, eye strain, irritation and, in rare cases, retinal detachment, while prolonged topical NSAID use may pose corneal risks. Broader, long-term, multi-centre studies are needed to confirm safety and effectiveness before this treatment can be widely recommended.”

Notes

1. Abstract number: ESCRS25-FP-3944, ‘Dose-dependent efficacy and safety of pilocarpine-diclofenac eye drops for presbyopia: a real-world single-center study,” by Giovanna Benozzi et al. Free paper session on ‘Miscellaneous topics in cataract and refractive surgery’, 16:30-18:00 hrs CEST, Sunday, September 14, https://pag.virtual-meeting.org/escrs/escrs2025/en-GB/pag/presentation/570375

In fact, research presented today (September 15) at the 43^rd Congress of the European Society of Cataract and Refractive Surgeons (ESCRS) [1], found that more than half of the general population in the USA and Europe experience dry eyes, yet only 20% of European patients and 17% of US patients were diagnosed, and they can wait years for professional help.

Dr Piotr Wozniak, refractive surgeon and dry eye specialist at Optegra Eye Clinics in Warsaw, Poland, and a lecturer and clinical instructor at Cardinal Stefan Wyszyński University in Warsaw, told the Congress: “Results from our studies reveal a substantial group of patients suffering without help. The European questionnaire explored why people don’t seek treatment. Many see dry eye as a normal part of aging and something to endure. As a medical doctor, I find this particularly concerning because a simple eye drop could offer significant relief – but many people aren’t even asking for help.”

Dr Wozniak presented findings from a survey of 2,003 adults in the US conducted in April 2024, and from an ongoing, international arm of the study conducted by Bausch and Lomb with over 5,000 adults in the UK, France, Germany, Poland, and Saudi Arabia: the ‘Needs Unmet in Dry Eye: Symptoms, Treatment and Severity’ (NESTS) study. In June 2025, the NESTS international arm surveyed 2,580 adults in the general population and 2,572 dry eye sufferers [2].

“In the NESTS study, we found that 58% of the general population reported experiencing dry eye symptoms, yet only one in five have received a formal diagnosis from a healthcare provider,” he said. “The large size of this study makes these results robust.

“The study explored the patient journey in detail. What stood out was that up to one-third of patients had experienced symptoms for more than five years before seeking professional help. NESTS also found that around half of sufferers experience symptoms every single day. The delay in seeking treatment is concerning, especially since dry eye is a progressive disease and early intervention can prevent a vicious cycle of inflammation.”

Other results from NESTS showed that 60% of dry eye sufferers waited at least four months before seeking help and 20% waited more than a year before talking to health care provider about their symptoms. Many sufferers stopped driving at night (17%), no longer wore makeup (14.8%), or reduced their use of heat or air conditioning (15.2%) due to their uncontrolled dry eye symptoms. One in three sufferers (34%) reported that their symptoms had worsened in the past year and only 9% said there had been an improvement.

Lubricating eye drops were the first and most common treatment, chosen either by the patient or by an eye or health care provider. Yet only 25% believed their current treatment was specifically tailored to their needs.

Dr Wozniak said: “NESTS also examined patient-provider interactions, revealing national differences. For example, in France fewer than half of dry eye sufferers had planned follow-up visits, while in Saudi Arabia, the majority, 84%, were proactively followed up by their providers.”

In the US study, eye dryness frequently affected 50% of survey respondents, and 80% experienced symptoms such as fatigue, itchy or watery eyes, but only 17% had a diagnosis from an eye care provider. Between 35-75% of people were very or extremely bothered by dry eyes, with reading, using electronic devices or driving being the most common activities to be disrupted; 70% lacked knowledge of treatment options; 40% were unaware that untreated dry eyes can cause other eye problems and vision loss; only about 25% visited an eye care provider every two years or more frequently; 67% of people with dry eyes waited six months or more to see an eye care provider, and 31% waited two or more years.

Dr Wozniak said: “These findings highlight the widespread impact of dry eye disease on quality of life, showing a large number of people suffering silently.

“We need to educate patients and the public on the causes, consequences and treatment options for dry eyes, as well as the importance of regular eye checks. In addition, we must support healthcare professionals in distinguishing between different types of dry eye and matching treatments appropriately. One person’s ‘dry eye’ can be very different from another’s.”

Diagnosis of dry eye often involves a combination of patient-reported symptoms, medical history and clinical tests. However, some patients are diagnosed only on the basis of symptoms and a standard eye examination, for instance with a microscope. Specific diagnostic tools include looking at the time it takes for a dry spot to appear on the cornea after a blink, using dye to stain the surface of the eye, measuring the concentrations of salts and other particles in tears, or an assessment of the Meibomian gland, which is responsible for producing the oily part of tears.

Left untreated, dry eyes can be very uncomfortable, can cause inflammation and a condition called blepharitis when eyelids become sore and inflamed. Symptoms include a sandy or gritty feeling, soreness, uncomfortable and painful eyes, itching or burning sensation, short-term blurred vision, and watery eyes. Dry eyes are more common in people over the age of 50 because the glands that make tears, particularly the oily component, become less effective, causing the tears to dry up too quickly and the front of the eye to become dry and irritated. The condition may also affect the outcome of nearly every ophthalmological surgery, including cataract and refractive procedures, making its diagnosis and management important, even before surgery takes place.

Dry, dusty, windy and cold conditions can also make eyes feel dry, as can air-conditioning, central heating, smoking and certain medical conditions such as autoimmune diseases and hormonal conditions.

ESCRS President, Dr Filomena Ribeiro, who is Head of the Ophthalmology Department at Hospital da Luz, Lisbon, Portugal, was not involved in the research. She commented: “These findings reveal the true extent of dry eye disease in the general population. It is concerning that such a small proportion of sufferers seek help for the condition, especially as it can make a real difference to the outcomes of ophthalmological surgery and also to their quality of life. Eye and health care professionals need to discuss this with patients when they see them and encourage people to have regular eye care checks.”

Notes

1. ESCRS25-PP-3336, ‘Dry eye symptoms, severity, treatment and unmet needs: an analysis of the United States of America and a multinational snapshot’, by Piotr Wozniak et al. Poster session: Ocular surface disease. 09:15-10:45 hrs CEST, Monday, September 15, https://pag.virtual-meeting.org/escrs/escrs2025/en-GB/pag/presentation/572147
2. Data from the NESTS international arm became available after the abstract was submitted. Therefore, the information in this release represents the most up-to-date data that will be presented to the Congress.

Cannabis use is increasing globally with an estimated 219 million users (4.3% of the global adult population) in 2021, but its long-term metabolic effects remain unknown. While some studies have suggested potential anti-inflammatory or weight management properties, others have raised concerns regarding glucose metabolism and insulin resistance, and the magnitude of the risk for developing diabetes hasn’t been clear.

To strengthen the evidence base, Dr Ibrahim Kamel from the Boston Medical Center, Massachusetts, USA and colleagues analyzed electronic health records from 54 healthcare organizations (TriNetX Research Network, with centers from across USA and Europe) to identify 96,795 outpatients (aged between 18 and 50 years, 52.5% female) with cannabis-related diagnoses (ranging from occasional use to dependence, including cases of intoxication and withdrawal) between 2010 and 2018.

They were matched with 4,160,998 healthy individuals (with no record of substance use or major chronic conditions) based on age, sex, and underlying illnesses at the start of the study, and followed for 5 years.

After controlling HDL and LDL cholesterol, uncontrolled high blood pressure, atherosclerotic cardiovascular disease, cocaine use, alcohol use and several other lifestyle risk factors, the researchers found that new cases of diabetes were significantly higher in the cannabis group (1,937; 2.2%) compared to the healthy group (518; 0.6%), with statistical analysis showing cannabis users at nearly four times the risk of developing diabetes compared to non-users.

While the authors note that more research is needed to fully explain the association between cannabis and diabetes, it may come down to insulin resistance and unhealthy dietary behaviours. Nevertheless, the study’s results have immediate implications for metabolic monitoring practices and public health messaging.

“As cannabis becomes more widely available and socially accepted, and legalized in various jurisdictions, it is essential to understand its potential health risks,” said lead author Dr Kamel. “These new sights from reliable real-world evidence highlight the importance of integrating diabetes risk awareness into substance use disorder treatment and counseling, as well as the need for healthcare professional to routinely talk to patients about cannabis use so that they can understand their overall diabetes risk and potential need for metabolic monitoring.”

The authors note that more research is needed on the long-term endocrine effects of cannabis use and whether diabetes risks are limited to inhaled products or other forms of cannabis such as edibles.

Despite the important findings, this is a retrospective study and cannot prove that cannabis use causes diabetes, and the authors cannot rule out the possibility that other unmeasured factors may have influenced the results despite efforts to reduce confounding bias via propensity score matching. This study has limitations due to lack of detailed cannabis consumption data and potential misclassification. The authors acknowledge inherent limitations of real-world data often result from inconsistent patient reporting in electronic medical records. They also note that there is a risk of bias because of imprecise measures of cannabis exposure and the reliance on participants to accurately report any cannabis use, even when they lived in places where the drug is illegal.