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Goals • Look at in a different light • What is myopia control • Why myopia control is important Myopia Control – • How myopia affects the decision making process for future procedures Why & How We Do It • Collaboration is key

Brianna Rhue, OD, FAAO 04.23.2021 [email protected] Linkedin: Brianna Rhue

Financial Disclosures -13.00 so what…

• Medical Advisory Board-OSRX • STAAR Study Investigator • Co-founder Dr. Contact Lens • Coopervision Consultant

A little about me…

Stop being so myopic about myopia management!

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My Myopic Passion Myopia and the Media

Our Digital Era The 20/20 Classroom

The 20/20 Classroom Prevalence of Myopia

2020 2050 1

2% 10% 30%

In 2016 the WHO and the Brien Holden Vision Institute recognized myopia as a issue.3

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Myopic Maculopathy

60 50

40 Visually Impaired 30 from MM Blind from MM 20

10 0 2015 2050

Fricke et al. Global prevalence of visual impairment associated with myopic macular degeneration and temporal trends from 2000 through 2050: systematic review, meta-analysis and modelling.

Incidence in US 100%

80% 41.9% 60% 5-19yo 40%

20%

0% 1900 1975 2000 2025 2050 Clinical - August 2018 Theophanous, Christos et al. “Myopia prevalence and risk factors in children.” Clinical ophthalmology (Auckland, N.Z.) vol. 12 1581-1587. 29 Aug. 2018, doi:10.2147/OPTH.S164641

Myopia, so What Why the Big Deal? • Myopic Maculopathy • Stretched blood vessels • Peripapillary atrophy • Posterior staphyloma • Lacquer cracks • Geographic atrophy • Subretinal hemorrhages • Choroidal neovascularization

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The Myopic Fundus See you in a year?

Wikipedia…

What is myopia costing us? What does 1 Diopter Mean

 The costs from the lost productivity of uncorrected myopia as well as permanent vision loss from MMD alone totaled $250 billion in 2015. • By reducing myopia by 1 Diopter we could prevent 1 million cases of vision loss. • $244 billion from uncorrected myopia • $6 billion from MMD 1 million -1.00 cases

Naidoo KS, Fricke TR, Frick KD, Jong M, Naduvilath TJ, Resnikoff S, Sankaridurg P. Potential Lost Productivity Resulting23 from 24 the Global Burden of Myopia: Systematic Review, Meta-analysis, and Modeling. Ophthalmology. 2019 Mar;126(3):338-346. doi: 10.1016/j.ophtha.2018.10.029. Epub 2018 Oct 17. PMID: 30342076.

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What is myopia control and why now? Where do I start?

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Brien Holden Calculator: https://bhvi.org/myopia-calculator-resources/

Analyze your Practice Kids… You have to want and LIKE to see kids Clinic By Refractive Error

10% 20% Myopia Hyperopia 70% None

Educate Yourself- Assess the Risk Factors Myopia Educational Resources • Genetics • Brien Holden Myopia Course • Near Work • https://bhvi.org/myopia-education-program/ • Outdoor time • Myopia Profile • Education • Myopiaprofile.com + Myopia Profile Facebook Group • Ethnicity • Vision By Design Conference • Age of Onset • Review of Myopia Management • Current prescription • Bullers2020.com Other (prematurity, diet, light exposure) • MiSight Certification •

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Genetics Environment

> 3 hours < 1.5 hours

3x risk 5-6x risk 2.6x risk

Rose KA, Morgan IG, Ip J, Kifley A, Huynh S, Smith W, Mitchell P. Outdoor activity reduces the prevalence of Mutti DO, Mitchell GL, Moeschberger ML, Jones LA, Zadnik K. Parental myopia, near work, school myopia in children. Ophthalmology. 2008 Aug;115(8):1279-85. doi: 10.1016/j.ophtha.2007.12.019. Epub achievement, and children’s refractive error. Invest Ophthal & Vis Sci 2002;43:3633-3640 2008 Feb 21. PMID: 18294691.

What is the Cycloplegic Refraction? Pre-Myopes

Age Normal Refractive Error @ Risk 6 years old +1.75  +1.50 +0.75 or less +0.75 @ 6-7yo is high risk 7 years old +1.50  +1.25 +0.50 or less 8 years old +1.00 +0.50 or less • Independent of family history, ethnicity and other optical and 9 years old +0.75 +0.25 or less environmental factors.7 10 years old +0.50 +0.25 or less 11 years old +0.50  +0.25 0.00 or less • Fastest change in refraction is year before onset. • Watch for eso and lag of accommodation • Tropicimide 1%, 2 drops 5 mins apart • Follow up every 6 months, sooner if risk Jones-Jordan LA, Sinnott LT, Manny RE, Cotter SA, Kleinstein RN, Mutti DO, Twelker JD, Zadnik K, Ethnicity tCLEo, factors are high or patient is changing Refractive Error Study Group. Early Childhood Refractive Error and Parental History of Myopia as Predictors of Myopia. Invest Ophthalmol Vis Sci. 2010;51(1):115-21

Height and Weight Charts Age of Onset

• The earlier the onset the higher chance for high myopia Chua SY, Sabanayagam C, Cheung YB, Chia A, Valenzuela RK, Tan D, Wong TY, Cheng CY, Saw SM. Age of onset of myopia predicts risk of high myopia in later childhood in myopic Singapore children. Ophthalmic Physiol Andrew Morgenstern, OD, FAAO, FNAP Opt. 2016 Jul;36(4):388-94. doi: 10.1111/opo.12305. PMID: 27350183.

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Axial Length Axial Length

37 • Emmetropia ~ 23-24mm

Axial Length Norms* Age Girls Boys European Chinese Axial Length & Refractive Error

6- 7 yo 22.75 mm 23.05 mm 22.33 mm 22.77 mm Refractive Error Axial Length 8-9 yo 23.29 mm 23.65 mm 23.05 mm 24.02 mm OD -4.75-0.75x010 23.91 OS -5.00-0.75x180 24.11 10-11 yo 23.76 mm 24.09 mm - -

12-14 yo 23.80 mm 24.25 mm 23.40 mm 24.69 mm Refractive Error Axial Length OD -5.50-0.50x180 27.28 *Caution must be taken when applying this data clinically, as many confounding factors OS -5.50-0.50x165 27.24 affect these norms, including but not limited to, gender and racial background. *Axial length normative data is already being used in biometers such as the Haag-Streit Lenstar Myopia and Oculus Myopia Master. *Refractive error does not necessarily correlate with Fuensanta A. Vera-Diaz, OD, PhD, FAAO. The Importance of Measuring Axial Length. Review of Myopia Management. August 9, 2020 https://reviewofmm.com/the-importance-of-measuring-axial-length-when-managing-childhood-myopia/ axial length

Axial Length and Myopic Disease What’s Normal AL Growth?

• Up to age 12 ~ 0.1mm per year • < 12 more than 0.1 is okay (grow faster) • >12 a little less than 0.1(grow slower) • >0.2mm monitor closely, may modify tx 24.84 mm 27.63 mm

*Diopters are easy to measure, but myopia *Diopters are easy to measure, but myopia management is about axial length control* management is about axial length control*

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Axial Length and Visual Impairment Axial Length 22%

40

35

30

25 Axial Length Visual Impairment Prevalence of Visual by age 60 Impairment by age 20 (odds ratio) 75 15 78% 24-26mm 1 (reference) 4% 10 5 26-28mm 2x 25% 0 28-30mm 11x 27% 22-23 23-24 24-25 25-26 26-27 27-28 >28 mm 30mm+ 25x 90% mm mm mm mm mm mm

Tideman JW, Snabel MC, Tedja MS et al. Association of Axial Length With Risk of Uncorrectable Visual Impairment for *Data from 110 patients with refractive error of +0.75 -21.00 Europeans With Myopia. JAMA Ophthalmology. 2016;134:1355-63.

Goal Axial Length

keep myopia below -6.00 • Heavy Eye Syndrome and • Kinked Optic Nerves axial length below 26mm

Shinohara, K. et al. “Retina Posterior Staphylomas in 46 Pathologic Myopia Imaged by Widefield Optical Coherence Tomography.” (2017). Image Courtesy Joshua Pasol, MD

5 Year Old Axial Length vs Refractive Refractive Error Axial Length K’s • 5 Year old- Parents worried about retina and wanted second opinion on OD -10.00-2.00x180 25.30 49.93@089/47.74@179 what to do OS -5.50-2.00x010 24.73 48.28@097/45.73@007 • Current Spectacle: • OD: -8.00-0.75x164 20/100 • OS: -5.00-1.75x178 20/60 • Refraction: • OD: -10.00-2.00x180 20/60- • OS: -5.50-2.00x010 20/50 • Cyclo: • OD: -10.00-2.00x180 • OS: -5.50-2.25x010

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5 Year Old Why the Big Deal

Retinal Myopic Refraction PSC Cataract Glaucoma Detachment Maculopathy

-1.00 to -3.00 2 2 3 2 -3.00 to -6.00 3 3 9 9 -6.00 to -7.00 5 3 21 41 >-7.00 44 126

TX: Update RX parents education full time wear Start Atropine 0.025% 1 drop QHS Flitcroft DI. The complex interactions of retinal, optical and environmental factors in RTC 4 weeks atropine follow up then every 3 months myopia aetiology. Prog Retin Eye Res. 2012;31:622-60.

Keeping Rx below -5.00… Incidence of Subtype of Cataracts in High Myopia

Myopia Odds of NS Odds of PSC

-0.50D to –1.99D 2.25 1.59

-2.00D to –3.99D 3.65 3.22

-4.00Dto –5.99D 4.54 5.36

-6.00D & up 3.61 12.34

• Risk of Glaucoma 67% No association found between Myopia & cortical opacities. • Risk of PSC Cataract 74% Chang, et al. The Association between Myopia and Various Subtypes of Lens Opacity, American Academy of • Risk of Retinal Detachment 98% Ophthalmology 2005, 112, 8: 1395-1401 • Risk of Myopic Maculopathy 99% 52

Brien Holden Myopia Calculator

PSC Cataracts Myopia Control: Why Every Diopter Matters (Mark Bullimore & Noel Brennan)

• Looked at 5 studies on prevalence of myopic maculopathy on 21,000 patients • PSC cataracts grow faster • 1 diopter increase is associated with a 67% increase • Can develop at a younger age in MM (myopic maculopathy) • Can adhere & weaken posterior capsule • Slowing myopia by 1 diopter should reduce the likelihood of developing MM by 40% • Increase risk of posterior capsular tears • Myopes lens zonules are more fragile and weak

53 Bullimore, Mark A. MCOptom, PhD, FAAO1*; Brennan, Noel A. MScOptom, PhD, FAAO2 Optometry and Vision Science: June 2019 - Volume 96 - Issue 6 - p 463–465

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AMD Risk Factor vs MM Why Every Diopter Matters

• Age Related Eye Disease  Reducing progression Study: by 1 diopter should • 3 benefits of lowering a patient’s level of myopia for the long-term care 1 • Antioxidants + Zinc risk lower risk of MM by • Less visual disability when uncorrected reduction of 25% 40%* • Better options and outcomes from, surgical myopia correction • Antioxidants alone risk • Reduced risk of blindness associated with higher levels of myopia reduction of 17% 6 • Zinc alone • An analysis of data from 15,000 patients demonstrated that each additional 1.00D of myopia is associated with a 25 percent increase in risk reduction of 21% visual impairment.2 AREDS

1. Bullimore, Mark A. MCOptom, PhD, FAAO1*; Brennan, Noel A. MScOptom, PhD, FAAO2 Optometry and Vision Science: June 2019 - Volume 96 - Issue 6 - p 463–465 *Bullimore, Mark A. MCOptom, PhD, FAAO1*; Brennan, Noel A. MScOptom, PhD, FAAO2 2. Bullimore MA & Ritchey E. Myopia control: An evidence-based comparison of the benefits and the risks. Optom Vis Sci2019; 96: E-abstract 190031 Optometry and Vision Science: June 2019 - Volume 96 - Issue 6 - p 463–465

Different Treatment Options Single Vision Glasses & Contacts

Do nothing… • • Single vision glasses & contacts have NO effect on slowing progression • 80% of practitioners acknowledged this • 64% of myopic children around the Under world are treated with a single vision option correction

James Wolffsohn: Global trends in myopia management attitudes and strategies in clinical practice – 2019 Update

5 Pillars of Myopia Management The Myopic Exam Dual • History (Family history, near work, outdoor time) Screen time/ Low Dose Focus/Soft Combo Outdoor time Atropine Multifocals Ortho-k • Age of onset, progression (if myopic) • Visual acuity (uncorrected, best corrected) • Corneal topography • Pupil size- dim and light • Binocular vision (lag, eso/exophoria, AC/A) • Axial Length (average of at least 5 readings) • Pachymetry • Objective/subjective cycloplegic refraction • 1% Tropicamide 2 drops 5 minutes apart • Anterior/posterior examination • IOP Pre-Myopes Myopes

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The 20/20 Classroom

Question: Is home confinement due to coronavirus disease 2019 associated with the burden of myopia? Findings: Cross-sectional study of 194904 8-10hrs photoscreening tests conducted in 123535 children, a substanal myopic shi (−0.3 diopters) was noted after home confinement due to coronavirus disease 2019 for children aged 6 to 8 years. The prevalence of myopia increased 1.4 to 3 times in 2020 compared with the

previous 5 years. 62 Wang J, Li Y, Musch DC, et al. Progression of Myopia in School-Aged Children After COVID-19 Home Confinement. JAMA Ophthalmol. Published online January 14, 2021. doi:10.1001/jamaophthalmol.2020.6239

Our Kids Today Screen time Recommendations

American Academy of

Tech (Text) Neck Sydney vs Singapore Study 6-7yo • Sydney • Singapore • n= 124 (Chinese origin) • n= 628 (Chinese origin) • Parental Myopia • Parental Myopia

=29% =43% = 28% =32% =43% = 25%

• 29.93 hrs/wk • 23.54 hrs/wk

• 13.75 hrs/wk • 3.05 hrs/wk Myopia Prevalence = 3.3% Myopia Prevalence 29.1%

Rose et.al. Myopia, Lifestyle and Schooling in Students of Chinese ethnicity in Singapore and Sydney. Arch Opthal/Vol 126 (no.4), Apr 2008

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Get Outside and Play Pre-Myopes & Myopes x 2

40- 80 minutes ↓23% to 50%

Dharani, R et al. “Comparison of Measurements of Time Outdoors and Light Levels as Risk Factors for Myopia in Young Singapore Children.” Eye 26.7 (2012): 911–918.

Outdoor Theories The Choroid

 Light-Dioptric Dopamine field of viewTheory •LightWinter› levelDifferences Months in defocus across • ›LightProgressviewing towards the distances3-4x UV Fasterend of in the indoor vs spectrumoutdoor slows environments. eye growth and 14 myopia  Outside = Dioptric value of 0

Ciuffreda KJ et al. Vision Res. 2007;47(9):1245-1252. Andrea C. Aleman, Min Wang, Frank Schaeffel

Don’t Forget About the Lens Emmetropia eye grows 0.1mm/year over 10 years lens thins/flattens

When it can thin anymore Myopia

71 72

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Spectacles Optical Correction

• Executive Bifocal • +1.50 Add • +1.50 Add with 3BI • 51% • Bifocals • 39% • Progressives (shorter corridor) • 11-33% • Esophoria or accommodative lag • +2.00, 2BI prism • ~40%

Optical Correction Effect of Spectacle Lenses Study- Single Vision vs Myovision

• 207 children (6-12 years old) • -1.50  -4.50 with 1 myopic parent • Followed for 2 years every 6 months to evaluate autorefraction and axial length Single Vision Myovision

Mean change in AR Mean change in AR -1.39 ± 0.07 -1.43 ± 0.10

Mean change in AL Mean change in AL 0.69mm ± 0.03 0.73mm ± 0.04

75 Kanda, H., Oshika, T., Hiraoka, T. et al. Effect of spectacle lenses designed to reduce relative peripheral hyperopia on myopia progression in Japanese children: a 2-year multicenter randomized controlled trial. Jpn J Ophthalmol 62, 537– 543 (2018). https://doi.org/10.1007/s10384-018-0616-3

Stellest Lens • The Stellest lens = "HALT" technology (Highly Aspherical Lenslet Target) Atropine • A constellation of aspherical lenslets on 11 rings • Creates a volume of defocus signal in front of the retina to slow down axial elongation • Known to prevent myopia development/ progression since • 1 year findings 187416 • Children wearing Stellest™ lenses had a 60% slow-down in myopia progression when compared to the control group wearing single vision lenses • High doses cause: • blurred near vision • light sensitivity • myopic rebound • Highly used in Asia

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Low Dose Atropine Atropine MOA Theories

• A non-specific muscarinic • Atom 1 Study (1999-2004)* receptor antagonist • Atom 2 Study (2006 – 2012)* • Anticholinergic that binds to • Atom 3 Study (April 2017- May 2021) M1, M2, M4, and M5 receptors • Lamp Study (January 2016- November 2017)* • May act on one or more • MOSAIC Study(2017-2020)* muscarinic acetylcholine receptors in the retina or • STAAR Study (April 2019- May 2024) directly on scleral fibroblasts to • CHAMP Study (June 2019- May 2024) slow eye growth Does not work by *All completed studies slowed progression of myopia by ~50-70% depending on • May prevent choroidal thinning blocking 17 concentration due to hyperopic defocus accommodation 8 8. McBrien NA, Moghaddam HO & Reeder AP. Atropine reduces experimental myopia and eye enlargement via a nonaccommodative mechanism. Invest Ophthalmol Vis Sci1993; 34: 205–215 *Clinicaltrials.gov  Myopia ~635 studies 17. Samuel T.-H. Chiang and John R. Phillips, “Effect of Atropine Eye Drops on Choroidal Thinning Induced by Hyperopic Retinal Defocus,” Journal of Ophthalmology, vol. 2018,

LAMP Study19 Atropine in US (Low-Concentration Atropine for Myopia Progression)

• Compared concentration of 0.05%, 0.025%, and 0.01% vs placebo over 1 year • Enrolled 438 children • Level 1 evidence supports • 4 to 12 years use of atropine to prevent • -1.0 D and astigmatism of -2.5 D or less myopia progression • Monitored: Cycloplegic refraction, axial length (AL), accommodation amplitude, • Rebound is minimized by pupil diameter, BCVA using low dose atropine, • 0.05% atropine was most effective in controlling SE progression and AL especially 0.01% elongation over a 1 year period

LAMP Study19 STAAR Study (Low-Concentration Atropine for Myopia Progression)

• Study of Atropine for the Reduction of Myopia Progression in Children • At year 2: • 0.025% and 0.05% showed better myopia control in the second year • 0.05% was still more effective • Unfortunately they got rid of the placebo group in the second year and started them on 0.05% to slow down progression

Yam JC, Jiang Y, Tang SM, et al. Low-Concentration Atropine for Myopia Progression (LAMP) Study: A Randomized, Double-Blinded, Placebo-Controlled Trial of 0.05%, 0.025%, and 0.01% Atropine Eye Drops in Myopia Control. Ophthalmology. 2019;126(1):113-124. doi:10.1016/j.ophtha.2018.05.029

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Low Dose Atropine Case The STAAR Study • Age 7 Asian ~ CC: Mom is nearsighted wanted exam

07.09.15 OD +0.50-0.25x180 No Rx given • Goal: to evaluate the efficacy of SYD-101 for slowing the progression of 7 yo OS +0.50-0.25x180 RTC 1 year myopia in children • Evaluating 2 different doses along with placebo 06.09.16 OD -0.75-0.75x005 1st Rx given CC Board is 8 yo OS -1.25 RTC 1 year blurry • 45 sites (38 in the US)

• May 2019- February 2024(4 year study) 06.14.17 OD -1.50-0.75x005 Update Rx • Children between the ages of 3-14 9 yo OS -1.75 RTC 1 year

06.18.18 OD -1.75-0.75x005 Update Rx Started 10 yo OS -2.50 RTC 3 months Atropine 0.01%

Low Dose Atropine Case Continued So What If No Tx…

06.18.18 OD -1.75-0.75x005 Update Rx 10 yo OS -2.50 RTC 3 months

Refraction A/P AL 09.19.18 10 yo OD -2.00-0.75x005 Continue 0.01% 23.91 OS -2.50 RTC 3 months 24.14

04.11.19 OD -2.00-0.75x005 Continue Soft MF 23.97 10 yo OS -2.50 RTC 6 Mo 24.15

10.09.19 OD -2.00-0.75x005 Start Soft MF 23.88 11 yo OS -2.50 RTC 6 Mo 23.98 Brien Holden Calculator: https://bhvi.org/myopia-calculator-resources/

Atropine Treatment Protocol Concentration Debate and Taper Schedule

• 1 drop 0.025% or 0.05% (QHS) daily • 0.01% vs 0.02% vs 0.025% vs 0.05% vs… • We don’t know which is superior right now • Start in kids 3 to 12 years of age who are at least • Factors to consider when selecting concentration: • Age of onset of myopia –0.50 D myopic with: • Rate of progression • History of at least 0.5 D progression over • Ethnicity last 6 months • Iris color • Family history of myopia • Family History and final Rx including sibling data • Near work/outdoor time • Indoor vs outdoor time • Other modalities added in over time • Treat for at least 2 years or to 15 years • Taper slowly over 6 months but monitor for rebound and progression of age Look for a 2mm dilation in pupil

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Atropine Treatment Protocol Atropine Follow up

• 4 week follow up (make sure they got their drops and are using them) • In the first 6 months, may still see progression • 3 month after starting to ensure no side effects/compliance • Start assessing treatment efficacy at 6 months • After 6 months, progression should slow to – 0.50 D change, or less/year • Assess for progression every 6 months • VA • Slows rate of progression by 30% - 70% concentration dependent • Binocular vision • A-scan If still progressing >-0.50D increase • • Refraction/Topography concentration or add a second treatment • If >0.25-0.50 D of change at 1year consider changing dosage • If stable for 2 years or past the age of 13Taper

Controlling Peripheral Focus

Center distance Aspheric multifocal

+2.50/D +1.50/D single vision

Paul Gifford’s Summary BLINK – Dual Focus

-3D+2.50D -3D+2.00D -3D+1.50D -3D+1.00D

95 96 Kim E, Bakaraju RC, Ehrmann K. Power Profiles of Commercial Multifocal Soft Contact Lenses. Optom Vis Sci. 2017 Feb;94(2):183-196.

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Power Profile MiSight FDA Approval-

• FDA approved first contact lens indicated to slow the progression of myopia in children between the ages of 8 and 12 years old at the initiation of treatment. November 2019 • “Today’s approval is the first FDA-approved product to slow the progression of myopia in children, which ultimately could mean a reduced risk of developing other eye problems,” said Malvina Eydelman, M.D.

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99 100

MiSight Study MiSight® 1 day clinical study: 0-72 months Part 1 1 Part 2 • Age: 8-12 • Three-year randomized, controlled clinical trial (4 • Age: 11-15 Slowed progression by: • Randomized • Double-masked study sites) • All subjects wearing MiSight® 1 day (omafilcon A) • Sites: UK; Portugal; Singapore; Canada • 135 children ages 8 to 12 at the start of treatment 59% • Sites: UK; Portugal; Singapore; Canada • 144 subjects enrolled and analyzed • MiSight vs. conventional soft contact lens cycloplegic spherical • 108 subjects enrolled and analyzed • 3 years • Results – (for the full three-year period) progression equivalent (SE) • 3 years in myopia of those wearing MiSight lenses was less and MS-3 45 than those wearing conventional soft contact lenses 74 56 51 49 52% ^ • In addition, subjects who used MiSight had less Control mean axial elongation of 36 48 60 72 change in the axial length of the eyeball at each 0M annual checkup. the eye M M M M MS-6 40 • There were no serious ocular adverse events in 70 52 49 48 either arm of the study ^

Test ^MS-3 and MS-6 had 1 and 6 subjects respectively 102 https://www.fda.gov/news-events/press-announcements/fda-approves-first-contact- 1. Chamberlain P et al. A 3-year Randomized attend the final visit but beyond the visit window for Clinical Trial of MiSight Lenses for Myopia primary outcomes lens-indicated-slow-progression-nearsightedness-children Control. Optom Vis Sci. 2019;96(8):556-567.

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® MiSight® 1 day clinical study MiSight 1 day clinical study – Change in Axial Change in spherical equivalent refractive error 0 to 72 months (Part 1 & 2) Length 0 to 72 months (Parts 1 & 2)

1.0 0.00 n=102 0.9 0.04 -0.25 102 0.07 98 mm • MS-6 group progressed 0.8 mm 104 0.08 102 -0.92D through 6 years mm -0.50 0.7 112 98 0.16 n=110 0.6 mm -0.75 96 0.05 80 112 0.5 0.07 mm • MS-6 group progressed 0.22 mm -1.00 0.07 less than 0.5mm 112 0.4 mm mm 96 through 6 years 0.10 mm 98 -1.25 0.3 n=110 • MS-3 & MS-6 group 112 0.24 104 progressed less than 0.2 mm 0.11 102 mm 0.2mm through final 3 -1.50 102 0.1 0.09 years 98 90 mm

Change inChange Axial Length(mm) n=102 -1.75 0.0 103 104 0 12 24 36 48 60 72 0 12 24 36 48 60 72

Change in Cycloplegic SERE (D) Study Time (Months) Study Time (Months)

MiSight® 1 day clinical study – Population MiSight® 1 day clinical study – 6 year change in context distribution (SERE) MS-6 group 0-72 months Eye Growth

25 1.0 0.9 20 98 0.8 23% 16.3 102 • 6-year progression (AL) 13.8 0.7 Mean 112 Mean in MS-6 matches 2-year 15 age: age: 11.311.3 • 23% of eyes in MS-6 group 0.6 12.1 16.1 progression for Original were refractively stable with a Control 10 112 total refractive change of 0.5 6.3 6.3 6.3 6.3 6.3 • A in a key 5 within -0.25D (SE) over the 0.4 4-year gain 5 3.8 96 period for eye growth Proportion of Eyes of Proportion 2.5 2.5 6-year study 1.3 1.3 0.3 n=110 98 0 104 • Similar finding observed 0 0.2 with SERE 0.1 102 0.0 n=102 0 12 24 36 48 60 72

Change in Refractive Error (D) through 6 years inChange Axial Length(mm) Study Time (Months) 105 106

Microbial Keratitis Incidence Astigmatism >1.25

MiSight 6 year study1 • Extended depth of focus Spectacles or no CL2 • Center distance Pure daily wear (DW) SCL2 7.4 in 10,000 • Can fit empirically with K’s and refraction

SCL 8-12 yo3 0 1 7

Ortho-k in children4 E G A P

Overnight wear hydrogel2

0 10 20 30 40 50 Incidence per 10,000 years

1. Woods J, Jones D, Jones L, Jones S, Hunt C, Chamberlain P, McNally J. Ocular health of children wearing daily disposable contact lenses over a 6-year period. Cont Lens Anterior Eye. 2021 Feb 3:S1367-0484(20)30204- 6. doi: 10.1016/j.clae.2020.11.011. Epub ahead of print. PMID: 33549474. 2. Stapleton F, Keay L, Edwards K, Naduvilath T, Dart JK, Brian G, Holden BA. The incidence of contact lens-related microbial keratitis in Australia. Ophthalmology. 2008 Oct;115(10):1655-62. doi: 10.1016/j.ophtha.2008.04.002. Epub 2008 Jun 5. PMID: 18538404. 3. Chalmers RL, McNally JJ, Chamberlain P, Keay L. Adverse event rates in the retrospective cohort study of safety of paediatric soft contact lens wear: the ReCSS study. Ophthalmic Physiol Opt. 2021 Jan;41(1):84-92. 4. Bullimore MA, Johnson LA. Overnight orthokeratology. Cont Lens Anterior Eye. 2020 Aug;43(4):322-332. doi: 10.1016/j.clae.2020.03.018. Epub 2020 Apr 22. PMID: 32331970.

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Soft Multifocal Case 5 Year Old -1.50 projection • Age 5 ~ CC: failed school screening

10.17.12 OD -1.50-0.50x117 1st RX given Patient 5 yo OS -1.50-1.25x004 RTC 1 Year moved away

02.15.16 OD -4.00-0.50x180 Update RX Lost to F/U 8 yo OS -4.50-1.25x180 RTC 6 Mo

Refraction A/P AL CL RX 03.11.18 OD -6.00-0.50x180 Start Soft MF 24.90 -5.75 10 yo OS -7.50-1.25x180 RTC 6 Mo 25.52 -7.50

10.10.18 OD -6.00-0.50x180 Continue Soft MF 24.92 -5.75 11 yo OS -7.50-1.25x180 RTC 6 Mo 25.55 -7.50

03.14.19 OD -6.00-0.50x180 Start Soft MF 24.92 -6.00 11 yo OS -7.50-1.25x180 RTC 6 Mo 25.54 -7.50

Which is which? Ortho-k and the LASIK ORTHO-K

LASIK vs Ortho-k Anatomically Ortho-K 8-10 microns = -5.00D Flap = 90-110 microns 50 microns

-5.00 Myope = 75 microns 235 -9.00 Myope = microns 135 microns 500 microns

114 • NaFL not visible if tear lens is <20 microns

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Ortho-K Candidates Ortho-K

• ~7 or older • -1.00 to -4.00 (FDA Approved up to -6.00) • Refraction • Myopia > Astigmatism • HVID • Ideal when Cyl < -0.75 WTR central also great option if cyl is >-1.00 • K’s between 41-45 • K’s • Topography

Lasik vs Ortho-k Ortho K Case Pre Lasik Post Lasik • 10 year old: • OD: -4.75 AL: 25.15 • OS: -4.50 AL: 25.46

OD: -2.50-0.50x090 117 OS: -2.50-0.50x135

1 Day follow up- 1 Week Follow up- Difference Maps Difference Maps

-1.77 -1.76 -4.75 -4.75

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1 year, 2 year, 3 year follow up Ortho-K 10 year old Pre Topo 1 Year 2 Year Difference Map

Enterin 1st AL Year AL Year AL Year AL g Rx 1 2 3 OD -4.75 25.19 pl 25.25 pl 25.73 pl 25.62 OS -4.50 25.46 pl 25.49 pl 25.88 pl 26.10

122 OD: -5.50-0.75x180, AL 27.26 OS: -5.50-0.75x165, AL 27.24

The Disruptees can become the Disruptors How to Bring Myopia Management to Your Practice

• You have a myopia clinic already … Take the time and go after it • Discuss pros and cons of treatment • Don’t get discouraged by a no • Have both parents present at consult

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How to Bring Myopia Management What do you need to be Successful to Your Practice • Patience because you already have patient’s • Develop your program before you start treating your first patient • Handouts/Brochures/Website Information • How will you present the options • Informed consents • Different visit- Myopia Consultation • This is a non-covered service billed outside of any managed care insurance or vision program • A-scan • Evaluate Chair Cost- what you charge maybe different from what your neighbor charges • Topographer • Global fee • Compounding • Per visit fee • Missed follow up visits? • Soft Multifocal/ Dual Focus fit set • Handouts • Ortho-k fit set or training certification • Contracts • Staff Trainings • Compounding pharmacy • Ortho-k training/ in office fitting vs empirical fitting

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Treating Myopia Stop, Collaborate and Listen

• The perfect storm: • Genetics • Indoor vs outdoor time • Near work/computers/phones/tablets • Online schooling • There is no cookbook approach as of yet • Only FDA approved treatment for myopia management now is the MiSight Lens • Look at each case individually to decide what is best for the child/parent/family 128

Completing the Circle of Myopia How does myopia control lead to better Management…. LASIK outcomes? • First pair of glasses • Fitted with contacts (if right for the child) • Interested in Refractive • Avoid complications of high myopia • LASIK (SMILE) • Less corneal tissue removal • PRK • Safer procedure • ICL • Overall better experience and better visual outcomes • Refractive Cataract Surgery

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LASIK Treatment When to Consider Refractive Sx?

Flap = 90-110 microns 50 microns • Ocular Maturity & Refractive Stability • No change in MRX of more than -0.50 in approx. 1 year • Approx. 16-18 microns for each Diopter -5.00 Myope = 75 microns • Corneal Flap: 90-110 microns (Adjustable) 235 • Best time could be after 1st year of College -9.00 Myope = microns • Goal is to only treat <40% of cornea • F/u after 1st semester & consider washing out ortho K lenses 135 microns • Ideal residual bed is >300 micron 500 • Serial Topographies • Best LASIK candidates are -1.00D to -6.00D microns

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Why LASIK may stop progression in young Patient Case CG myopes…… OD: -8.00 -2.25 X 170 OS: -8.00 -3.00 X 175 • LASIK at an early age decreases Pach: 557 Pach: 541 progression of myopia • Peripheral treatment zones treat hyperopic defocus • Less possible enhancements

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OD: -8.00 -2.25 X 170 Patient Case CG OS: -8.00 -3.00 X 175 Patient Case CG Pach: 557/541

6.5 OZ / 100 microns flap 6.0 OZ / 100 microns flap

• Tissue Altered: 42%/ 44% • Tissue Altered: 37%/ 38% • Residual Stromal Bed: 326/302 • Residual Stromal Bed: 355/ 338

By modifying the OZ this patient was

135 still able to undergo LASIK 136

Patient Case RM Patient Case RM OD: -6.00 -1.25 X 178 OS: -5.25 -1.75 X 170 Pach: 480 Pach: 469

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Patient Case RM OD: -6.00 -1.25 X 178 Patient Case PG OS: -5.25 -1.75 X 170 Pach: 480/ 469 OD: -10.50 -3.50 X 180 OS: -9.50 -3.75 X 179 Pach: 512 Pach: 515

PRK OU / 6.5 OZ / 58 micron flap LASIK OU / 6.0 OZ / 100 micron flap • Tissue Altered: 29%/ 31% • Tissue Altered: 38%/ 39% • Residual Stromal Bed: 339/ 326 • Residual Stromal Bed: 296/ 287

Due to thin pachs this patient was a

better candidate for PRK 139 140

• OD: -10.50 -3.50 X 180 Patient Case PG Patient Case PG • OS: -9.50 -3.75 X 179 • Pach: 512/515

LASIK OU ICL OU • 6.0 OZ / 90 micron flap • Two Laser Peripheral Iridotomies in each eye • Tissue Altered: 44%/ 42% Corneal Tissue Unaffected • Residual stromal bed: 287/ 298 • • Uncorrected VA at 1 week PO: 20/20 OD, OS

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Patient Case AK You Can Do It! OS: -13.25 -1.50 X 109 20/20 OD: -3.50 -0.75 X 125 20/60 1. Get your elevator pitch down Hx of corneal ulcer with Scar Pach: 553 2. Learn how to talk with your patients and ask for referrals 3. Present the options 4. Get your staff involved 5. Create your program 6. Figure out your fees 7. Don’t be afraid to charge for your expertise and time 8. See kids earlier 9. Start changing little lives 10. Enjoy what you do! 143 144

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What will it Take? MGD and Kids

• All of us working together • Pediatricians getting onboard 8 • OMD referrals as they are also on the front lines when doing Lasik consults, cataract consults, retinal detachment consults or when seeing myopia patients in general. • Proper school screenings 12

Thank you! Brianna Rhue, OD, FAAO [email protected] Linkedin Brianna Rhue

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