Background: Presbyopia is an age-related decline in accommodative function that progressively impairs near vision. Although optical correction remains the conventional treatment, pharmacological and non-pharmacological alternatives have attracted increasing interest. This review examines the clinical evidence supporting non-surgical interventions, including conventional treatments, phytotherapy, nutritional supplementation, and complementary approaches.
Methods: A narrative review of published clinical investigations, ophthalmological literature, and regulatory documents was conducted, focusing on non-surgical interventions for presbyopia. Randomized trials, comparative clinical studies, and relevant clinical evidence concerning established optical correction were considered. Studies evaluating visual fatigue or accommodative dysfunction without a clearly defined presbyopic population were analyzed separately as indirect evidence. Surgical procedures and interventions supported exclusively by preclinical findings were excluded.
Results: Spectacles and contact lenses provide established optical correction of near vision. Topical miotic agents, including pilocarpine, aceclidine, and carbachol combined with brimonidine, demonstrated clinically meaningful improvements in near visual acuity in randomized trials. In GEMINI 1, pilocarpine 1.25% produced a three-line or greater improvement in near visual acuity in 30.7% of participants compared with 8.1% receiving vehicle. In pooled NEAR trials, pilocarpine 0.4% achieved the corresponding primary endpoint in 40.1% versus 19.1% of participants. Clinical studies of herbal formulations containing Cassiae Semen, wolfberry, and Dendrobium huoshanense, as well as Cassiae tea, reported improvements in near visual performance or subjectively measured accommodative amplitude. Antioxidant supplementation demonstrated modest improvements in accommodative measurements in selected adults, although the evidence was frequently derived from populations with visual fatigue rather than established presbyopia. Visual exercises did not demonstrate objective improvement in near visual acuity or accommodative amplitude in a presbyopia-specific clinical investigation.
Conclusions: Optical correction and approved topical miotic agents provide established non-surgical options for improving near vision in presbyopia. Phytotherapeutic and nutritional interventions have produced favorable findings in selected clinical studies, but their efficacy, reproducibility, and long-term safety remain insufficiently established. Current evidence does not demonstrate that these interventions restore the physiological accommodation lost through age-related crystalline lens stiffening.