COOKIE Issue 12: The Myopia Crossover Issue

THE WORLD’S FIRST FUNKY OPTOMETRY MAGAZINE

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THE MYOPIA CROSSOVER ISSUE

July 2023

cookiemagazine.org

Seeing Eye to Eye The door is open for ODs and MDs to work together on a new myopia co-management paradigm

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Letter to Readers

Beyond Specialties Fostering a cross-disciplinary approach to myopia management

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ur myopia center, situated in the heart of a bustling Philippine metropolis, is constantly busy examining and managing myopic kids. Children whose myopia exceeds 6.00D require very detailed retinal examination to determine that the retina is intact and attached.

An ophthalmologist specializing in the retina, who practices at our clinic, plays a crucial role in assisting with these particular patients. Additionally, ophthalmologists are capable of conducting examinations on children with extremely high myopia to assess for conditions such as cataracts, glaucoma, and myopic maculopathy. They can also prescribe atropine, especially to children whose parents have a history of high myopia — wherein a myopia control strategy is proven to be more effective if combined with low doses of atropine.

These instances above underscore the potential benefits that can result from collaboration between optometrists and ophthalmologists, benefiting both professionals and, most importantly, the patients.

Our associate optometrists can very well conduct cycloplegic refraction and binocular vision assessments.

However, incorporating the insights and techniques of ophthalmologists can further enhance these procedures. Indeed, when it comes to myopia patient care, the collaboration between optometrists and ophthalmologists proves that two heads are truly better than one.

Referrals, in both directions, exemplify the crossdisciplinary approach we embrace. Our myopia center often receives quite a number of pediatric referrals from ophthalmologists for orthokeratology fitting. These ophthalmologists recognize orthokeratology as an effective tool for slowing down myopic progression.

Dr. Dwight Ackermann, editor of Review of Myopia Management, noted that myopia management — long championed by optometrists, is now being embraced, too, by ophthalmologists, saying: “… pediatric ophthalmology plays a critical role in ensuring myopic children receive the highest level of care.”

He cited the Myopia Consensus Statement 2023 issued by the World Society of Paediatric Ophthalmology and Strabismus, which states that: “There is sufficient evidence to warrant the adoption of myopia prevention and control measures in clinical practice in children with progressive myopia of childhood.”

By detailing the interventions to slow the progression of myopia, the Consensus Statement demonstrates that the global pediatric ophthalmology community is more broadly embracing myopia management.

Parents have the option to see either an optometrist or an ophthalmologist for their myopic child. After all, when they realize the valuable contributions that both professionals can provide, it is the child who ultimately benefits the most.

As COVID-19 gradually fades into the horizon, the alarming rise in myopia cases shows no signs of slowing down. It is projected to affect a staggering 5 billion people, roughly half of the world's population, by 2050. This stark reality requires combined efforts, even outright collaboration, between the two main professional groups in our industry.

Needless to say, siloing and turf protection would only impede progress. So, all hands must be on deck!

Best, Dr. Carmen Abesamis-Dichoso

OD, MAT, FIACLE, FPCO, FBCLA, FAAO

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COOKIE MAGAZINE | July 2023

In This Issue...

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The Great Myopia Debate How big a role does genetics play in the development of myopia?

The Promise of Ortho-K An alternative to laser eye surgery, orthokeratology proves effective at correcting myopia

Cover Story

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MY

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Caught in the Crossover Do ophthalmologists and optometrists have different intervention strategies for myopia management?

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Optics

Cool Optometry

Seeing Eye to Eye The door is open for ODs and MDs to work together on a new myopia co-management paradigm

Enlightenment

Kudos

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Championing Myopia Control WCO’s Dr. Sandra Block addresses today’s growing need to elevate the standard of care in myopia management

24 Innovation

A Vision for Vision New Zealand’s trailblazing optometrist proves that teamwork makes the dream work Heeding the Wakeup Call Through collaboration and effective management strategies, eye care professionals can combat the global myopia epidemic

Conference Highlights

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Specs and Control Embracing the promise of myopia control-specific spectacles

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Empowering Optometry in India APOC 2023 highlights outreach programs, regulatory developments, and improved eye care Silmo Singapore 2023 New thoughts on myopia control, new trends in style

COOKIE MAGAZINE | July 2023

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Advisory Board Members

Matt Young CEO & Publisher

Dr. Carmen Abesamis-Dichoso Abesamis Eye Care & Contact Lens Center, Manila, Philippines

Dr. Joseph J. Allen

Hannah Nguyen COO & CFO

Doctor Eye Health, Minnesota, USA hello@doctoreyehealth.com

carmen.dichoso@gmail.com

Gloria D. Gamat Chief Editor Mapet Poso Editor Maricel Salvador Graphic Designer

Dr. Kristie Nguyen

Perez and Associates and Phan-Tastic Eye Care , Florida, USA

Dr. Mark Eltis

View Eye Care, Toronto, Canada drmarkeltis@vieweyecare.com

kristie817@gmail.com

Writers Andrew Sweeney Ben Collins Brooke Herron Jenna Passut Joanna Lee Matt Herman Tan Sher Lynn Ruchi Ranga Customer Care International Business Development Brandon Winkeler Robert Anderson Adam Angrisanio

Published by

Dr. Monica Chaudhry

Learn Beyond Vision, New Delhi, India monica.rchaudhry@gmail.com

Dr. Elise Brisco

NearSight, California, USA elisebrisco@hollywoodeyes.net

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Cool Optometry |

MYOPIA INTERVENTIONS

Caught in the Crossover

Do ophthalmologists and optometrists have different intervention strategies for myopia management? by Ben Collins There is significant overlap between the fields of ophthalmology and optometry, and the treatment of myopia is no exception. COOKIE Magazine caught up with one of our regular contributors, Dr. Jeffrey Walline, to get the lowdown on what's hot in myopia management right now, and whether optometrists and ophthalmologists have different strategies when it comes to myopia control.

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t's reassuring to know that eye health professionals are wellinformed about the myopia epidemic and some are actively collaborating to evaluate, innovate, and educate each other on the issue.

are working together to tackle the epidemic, what similarities and differences one might expect to find in their respective treatment approaches and what innovative methods are showing promise.

We asked Dr. Jeffrey Walline, associate dean for research at the Ohio State University College of Optometry in the US, how ophthalmologists and optometrists

They got this!

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“The American Academy of Ophthalmology created a task force on myopia and included

COOKIE MAGAZINE | July 2023

representatives from the American Academy of Optometry, the American Academy of Family Physicians and the American Academy of Pediatrics.

They wrote a white paper1 on the topic,” shared Dr. Walline.

“There is also a group of industry partners called the Global Myopia Awareness Consortium (GMAC)2 that work together to improve public awareness about myopia and myopia control. They include optometry and ophthalmology association members, such as the Academy of Optometry, the World Society of Pediatric Ophthalmology and Strabismus, and the International Agency for the Prevention of Blindness,” he added.

So, what’s working?

What is currently best practice when it comes to myopia management, you ask? What tried and proven treatment methods are out there?

“In the United States, we can offer our patients soft multifocal contact lenses, orthokeratology, and [offlabel] low-concentration atropine eye drops,” Dr. Walline continued.

These treatment options (or a combination of them) have proven to be equally effective in the fight against myopia.3

Opt or ophth: What will it be?

Do ophthalmologists and optometrists have different preferences when it comes to prescribing treatments?

"Both optometrists and ophthalmologists [depending on what's allowed where they are] can offer the full variety of options available to patients for myopia control,” said Dr. Walline. “All of the treatments provide approximately the same amount of myopia control for patients, and you can’t predict which one will work best for an individual patient. So, we should provide the option that best suits the patient’s needs because they are most likely to be compliant with that modality. Having said that, optometrists are more likely to offer soft multifocal and orthokeratology contact lenses for myopia control than ophthalmologists, and ophthalmologists most frequently prescribe low-concentration atropine,” he opined.

“Patients should also ask their eye care practitioner what options are available for myopia control because there are many optometrists and ophthalmologists who don’t offer all three modalities for myopia control,” he noted.

Given there are varied factors leading to myopia development, a holistic approach makes sense. As does choosing a treatment regime that the patient is most likely to be compliant with.

A myopian future, anyone?

Soft multifocals, orthokeratology, and [off-label] low-dose atropine are the usual options being utilized to help manage myopia. But what about emerging innovative technologies and treatments that might have potential to move forward?

“The only treatments available in the United States today are soft multifocal contact lenses, orthokeratology, and [off-label] low concentration atropine, Dr. Walline shared. “Innovative treatments on

the horizon may include spectacles produced specifically for myopia control, and red light therapy. The glasses are marketed throughout the world, but have not yet earned Food and Drug Administration (FDA) approval for myopia control.”

“In Asia, children are provided instruments to use at home that shine red laser light at the eyes two times per day for three minutes each time, and that is reported to slow the progression of nearsightedness.

However, that therapy is not available in the United States and requires much more study of the effects on eye health, vision, and progression of nearsightedness before it will be used in clinics,” he added.4 Dr. Walline offers an anecdotal prediction for when these treatments might become available in the US. “I don’t think the FDA ever works on a specific timeline. Honestly, I don’t know much about the approval process for any of the three options,” he said. “Typically, the FDA requires data collected in the United States, and I think SightGlass (CooperVision/ Essilor, CA, USA/Paris, France) has collected data in the US. However, you never know for sure what they will allow, so I hate to speculate.

I also haven’t seen any data presented beyond one year for SightGlass, so I don’t know how effective they are.”

He’s optimistic, however, about the effect emerging technologies and treatments could have amid the current myopia milieu.

“I do expect that an FDA-approved myopia control spectacle will change the game (in the USA) dramatically.

Interestingly, the glasses don’t have to be specifically prescribed by a doctor, but they should specifically be fitted to the child by an optician or doctor. In other words, a doctor will write a prescription to correct myopia, then the parent can get regular glasses or myopia-control glasses,” Dr. Walline explained.

“However, the glasses should be fit so that the patient looks directly through the center of the lens, which is the clear part to allow clear

distance vision.”

Clear distance vision This is perhaps a good mantra to help lead us onwards to a future where we have greater control over and understanding of myopia progression. There are a lot of moving parts and as yet unknowns within the myopia epidemic. What is clear, though, is that this kind of crossindustry/professional cooperation and sharing of knowledge can only be of benefit.

Long may the crossover continue!

References 1. Modjtahedi BS, Abbott RL, Fong DS, et al. Reducing the Global Burden of Myopia

by Delaying the Onset of Myopia and Reducing Myopic Progression in Children: The Academy’s Task Force on Myopia.

Ophthalmology. 2021;128(6):816-826.

2. Global Myopia Awareness Coalition. Available at https://www.myopiaawareness.org/.

Accessed on June 3, 2023.

3. Walline JJ, Lindsley KB, Vedula SS, et al.

Interventions to slow progression of myopia in children. Cochrane Database Syst Rev. 2020;1(1):CD004916.

4. Jiang Y, Zhu Z, Tan X, et al. Effect of Repeated Low-Level Red-Light Therapy for Myopia Control in Children: A Multicenter Randomized Controlled Trial. Ophthalmology.

2022;129(5):509-519.

Contributing Doctor Dr. Jeffrey J. Walline, OD, PhD, is the associate dean for Research at The Ohio State University College of Optometry. He received his Doctor of Optometry degree from the University of California, Berkeley School of Optometry, and received his Master’s and PhD degrees from The Ohio State University College of Optometry.

Dr. Walline has led several pediatric contact lens studies, and he is the study chair of the Bifocal Lenses In Nearsighted Kids (BLINK) Study, a National Eye Institutesponsored randomized clinical trial to investigate the myopia control effects of soft multifocal contact lenses. walline.1@osu.edu

COOKIE MAGAZINE | July 2023

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Cool Optometry |

GENETICS

In the debate about optometry's great pandemic — myopia — environmental components like time spent outside and away from screens seem to be the more obvious determining factors. What has been long established but discussed less these days, however, is the role genetics plays in making people more likely to develop myopia. And while it's understandable to focus on environmental factors that can be altered, it's also important to continue studying DNA's influence.

Gene therapy is developing at a rapid pace and potential new treatments could be on the horizon for myopia.

Everyone is eager for such news as both ophthalmology and optometry deal with one of the most formidable public health crises in the century.

So let's examine the relationship between myopia and genetics and consider what optometrists can learn as a result.

The Great Myopia Debate How big a role does genetics play in the development of myopia?

by Andrew Sweeney

Is myopia genetic? While lifestyle factors are closely associated with this condition, it is still important to emphasize that genetics plays a significant role in determining myopia susceptibility and severity.

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e all know genetics plays a crucial role in many aspects of our physical makeup, from the color of our eyes to whether or not we have earlobes — or when we are hardwired to avoid certain types of foods. If our genes contribute to

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our 'nature', then it's also fair to say that ‘nurture’ plays a crucial part in determining who we are as people — and some of the most common conditions around are very much caused by nurture.

COOKIE MAGAZINE | July 2023

Genetic loci and associated syndromes Dr. Cheryl Chapman, president of the American Academy of Orthokeratology and Myopia Control (AAOMC) and the owner of Gretna Vision Clinic in Gretna, Nebraska, is a renowned orthokeratologist.

Her dedication to advancing myopia management is evident through the establishment of a comprehensive myopia management clinic within her practice. She emphasizes that genetics plays a major role in the presence of myopia.

“It is clear that genetics plays a role in the development of myopia,” Dr. Chapman said. “Heritability studies generally estimate the inheritance of myopia to range somewhere between 60% and 80%. At this time, nearly 200 genetic loci linked to myopia have been identified.”

“We know that a family history of myopia not only increases the risk of a child developing myopia but also increases the risk of them experiencing a fast progression of myopia. A child with one myopic parent has a 1.5-times greater risk of developing myopia. A child with two

myopic parents has a three-times greater risk of developing myopia,” she continued.

Dr. Chapman said that it’s important for optometrists to remember that there are several inheritable syndromic conditions that are often associated with myopia and that the pathogenesis of secondary syndromic myopia in these conditions is often different from that of primary myopia.

As such, these cases often respond differently to standard myopia management therapies, which can have a considerable impact on patient outcomes. Examples of such conditions include Marfan's Syndrome and Ehler's Danlos Syndrome, both genetic conditions that affect the body’s connective tissue; and Stickler's Syndrome, a hereditary condition characterized by a unique facial appearance, abnormalities in the eyes, hearing loss, and joint issues

Early intervention is key “An alternate treatment that may sometimes be more effective in these cases is the use of ophthalmic pharmaceuticals that lower intraocular pressure, such as prostaglandin analogs. Secondary syndrome myopia cases can be very severe and onset at a young age, so it is important for clinicians to be aware of these details and should consider it a red flag if a young child has myopia where the dioptric power reads higher than the patient's age,” Dr. Chapman explained.

“For example, if you have a four-yearold that is a -5.00 D or higher myope, that would warrant communication with the child's pediatrician and should include a recommendation for a genetic workup,” she continued.

“Another red flag for clinicians to watch out for would be if the myopic patient exhibits other signs of syndromic conditions that could manifest with variations in physical attributes or developmental milestones,” she said.

“Eye care providers should proactively work with primary

care providers like pediatricians to perform genetic testing when appropriate to uncover syndromic conditions associated with myopia.

Implementing patient intake forms and questionnaires to determine the genetic risk of myopia based on parental myopia and to screen for signs and symptoms of syndromic conditions is important,” she added.

The good news, however, is that according to Dr. Chapman, there is a constant stream of new science and study outcomes for optometrists to continue understanding the role genetics play in myopia. She recommends seeking membership resources and continuing education from entities like the AAOMC as an actionable and sustainable step.

She added that the alignment organizations like hers can limit the amount of time required to research new developments and how to implement them.

Don’t be a skeptic about epigenetics

changes that affect what genes are turned on and off can be passed down in families. Attempts to reveal how epigenetic changes impact myopia development are underway and may provide great insight into future myopia treatments,” she said.

“I believe we will see massive developments in our ability to screen for myopic risk factors, as well as our ability to halt the progression of myopia. I anticipate our understanding of the role of genetics in myopia will drive some of these developments. In fact, I would not be surprised to see the advent of buccal swab testing to pinpoint those individuals most at risk,” she concluded.

Contributing Doctor

This is important, as Dr. Chapman is keen to emphasize that practitioner education and consumer awareness campaigns are two of the most important things that can help shift more providers to being highly trained in modern-day myopia treatment.

Practitioner education is important because it improves access to care. Consumer awareness about treatments currently available is key to ensuring that they can have an open discussion with their provider on new options like epigenetics.

“Epigenetics is a fascinating area of study that can shed light on the combined impact that genetics and environment can play on the development of myopia. Put very simply, epigenetics refers to certain genes being turned on or off due to environmental influences.

Interestingly, it has been found that epigenetic changes can be heritable,” Dr. Chapman said.

“Even though epigenetic changes don't change the DNA code, the

Dr. Cheryl Chapman, OD, IACMM, FIAOMC, FAAO, Diplomate ABO, is the president of the American Academy of Orthokeratology and Myopia Control (AAOMC) and works in private practice in Gretna, Nebraska. She has instituted a full scope Dry Eye Subspecialty as well as a Myopia Management Subspecialty within her practice.

Dr. Chapman is the co-founder of Peeq Pro, a designer of the patent-pending device, the Peeq Waiva, and a co-creator of multiple products and services for Peeq Pro. In addition to working oneon-one with doctors to implement practice protocols, she lectures within the optometric community as well as to local pediatricians and ophthalmologists. Serving as an adjunct assistant professor at the University of the Incarnate Word Rosenberg School of Optometry, Dr. Chapman also enjoys working closely in training fourth-year extern students in current dry eye therapies, myopia management strategies, and practice management. She is a graduate of the University of Houston College of Optometry. gretnavisionsource@gmail.com

COOKIE MAGAZINE | July 2023

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Optics | ORTHO-K

The Promise of Ortho-K

An alternative to laser eye surgery, orthokeratology proves effective at correcting myopia

by Andrew Sweeney

There are a number of techniques currently available for the correction of myopia, and orthokeratology is gaining popularity, especially in Asia. The strong body of evidence supporting its efficacy is growing, along with a stead stream of positive anectodal reports from clinicians.

come across sensationalized reports online regarding rare instances of unsuccessful procedures. After all, Dr. Google has become the modern patient's go-to source for a second opinion.

An alternative to LVC that has gained popularity in Asia among both medical professionals and the community is orthokeratology, commonly referred to as Ortho-K, or corneal refractive therapy. The latter is a trademarked brand name for lenses manufactured by Paragon Vision Sciences (Gilbert, Arizona).

It's similar to champagne, where all champagne is sparkling wine, but not all sparkling wine is champagne.

The name Ortho-K has become a commonly used term encompassing a range of products.

Ortho-K: The champagne of optometry Ortho-K is quite remarkable as it offers a non-surgical therapeutic approach involving reversible tissue manipulation. Patients wear specialized lenses overnight that alter the shape of the front of the cornea via controlled hydrostatic pressure.

Ortho-K aims to provide the benefits of successful LVC without the potential complications that concern many patients, as individuals always have the option to revert to normal glasses and contact lenses without permanent changes.1

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ith the emergence of new techniques and technologies for myopia correction, millions of people now have the opportunity to free themselves from glasses or contact lenses — for a variety of reasons.

Some simply dislike the idea of relying on visual aids like ocular crutches, particularly during sports activities.

For others — such as a certain media writer who wishes to fix his eyes

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because glasses do not complement his overall ‘Viking’ aesthetic — the reason can be more unconventional.

Dr. Cheryl Chapman, presidentelect of the American Academy of Orthokeratology and Myopia Control, is someone who knows a thing or two about myopia and techniques designed to correct it, like Ortho-K. She views the technique as remarkably beneficial for patients as it removes a number of safety concerns they otherwise might have.

It’s also a notable advancement compared with previous techniques.

However, many potential patients are still hesitant to undergo permanent myopia correction, often due to misconceptions primarily associated with laser vision correction (LVC).

While LVC generally exhibits a high margin of safety and patient satisfaction, it is not difficult to

“When Ortho-K was first developed, the lens designs were not as sophisticated as they are today,” Dr. Chapman shared. “The advent of advanced corneal topography that allows practitioners to map the shape of the cornea in great detail along with advances in the

COOKIE MAGAZINE | July 2023

equipment that manufactures the lenses has opened many doors.

This advanced technology along with the practitioner's higher level of understanding about lens designs has led to the ability to treat more complex and advanced cases.”

“Ortho-K is an extremely important treatment option and is common in robust myopia management practices due to its ability to treat patients who are not good candidates for other therapies,” Dr. Chapman continued. “I find Ortho-K to be particularly useful with patients that have astigmatism because the daily disposable soft myopia management lenses do not work well with astigmatism cases.

Ortho-K is also wonderful for patients that have specific lifestyle goals.”

Who is the ideal candidate for Ortho-K? Some people want to correct their myopia because of the discomfort they feel while playing sports and wearing glasses. Dr. Chapman said that these individuals are perfect candidates for Ortho-K. She reported that several people at her practice who are involved in high-intensity sports, such as baseball players, gymnasts, swimmers, etc., all reported improved performance when using Ortho-K to manage their myopia.

She also favorably compared it to another myopia management technique, low-dose atropine, as Ortho-K doesn't require glasses and is a non-pharmaceutical approach.

However, even if a potential patient is the sportiest person alive and just cannot continue with glasses, it is important to note that not everyone is suitable for Ortho-K. According to Dr. Chapman, good candidates generally need to exhibit good personal hygiene, be highly motivated to adhere to the treatment, and demonstrate good compliance with recommended care and maintenance. Conversely, individuals with irregular sleep patterns, poor hygiene, emotional immaturity, a history of corneal dystrophy or disease (such as herpes

simplex, recurrent corneal erosions, keratoconus, endothelial dystrophy, etc.), or corneal scarring should not undergo Ortho-K. “There are also considerations with regard to the patient's prescription and cornea shape that can determine candidacy for Ortho-K. Often, the skill level of the specialist in charge influences their ability to treat moderate to high-level prescriptions,” Dr. Chapman clarified.

“Prescriptions that range above -4.00 or have astigmatism greater than -1.50 tend to be more complex,” she added. “The shape of an individual's cornea can increase complexity and is determined with corneal shape analysis performed by the eye care practitioner with a computerized topographical scan.”

idea of LVC to be a bit overwhelming, consider using Ortho-K instead. If patients can maintain a consistent routine of using the lenses at night, they will likely soon experience a significant increase in their quality of life.

This is all great news for sports fanatics wanting to ditch their glasses, and many others.

References 1. Barnard Levit Optometrists. Corneal Refractive Therapy. Available at http://www.barnardlevit. co.uk/contact-lenses/corneal-refractivetherapy-crt/. Accessed on Monday, May 29, 2023.

2. Bullimore MA, Sinnott LT, Jones-Jordan LA. The Risk of Microbial Keratitis with Overnight Corneal Reshaping Lenses. Optom. Vis. Sci. 2013;90(9):937-944.

Emphasis on ocular hygiene “Another concern with Ortho-K, as with other contact lenses, is the risk of eye infection. The safety of overnight Ortho-K wear has been well studied. Bullimore et al. reported that ‘the overall estimated incidence of microbial keratitis (MK) is 7.7 per 10,000 years of wear... the risk of MK with overnight corneal reshaping contact lenses is similar to that with other overnight modalities.’2 The risk is low, but it is extremely important for Ortho-K patients to practice good hygiene,” she reiterated.

Despite these well-placed warnings, however, Dr. Chapman is keen to emphasize the efficacy of Ortho-K. Pointing out that it has been studied extensively, she said that the medical community should have a high level of confidence in the technique.

"Medical research consistently highlights that Ortho-K can slow progression by about half or achieve a 50% reduction in progression," noted Dr. Champman, adding that many clinicians utilizing Ortho-K designs often observe results that exceed the efficacy reported in the studies.

So, if you have patients who want to correct their myopia but find the

Contributing Doctor Dr. Cheryl Chapman, OD, IACMM, FIAOMC, FAAO, Diplomate ABO, is the president of the American Academy of Orthokeratology and Myopia Control (AAOMC) and works in private practice in Gretna, Nebraska. She has instituted a full scope Dry Eye Subspecialty as well as a Myopia Management Subspecialty within her practice.

Dr. Chapman is the co-founder of Peeq Pro, a designer of the patent-pending device, the Peeq Waiva, and a co-creator of multiple products and services for Peeq Pro. In addition to working oneon-one with doctors to implement practice protocols, she lectures within the optometric community as well as to local pediatricians and ophthalmologists. Serving as an adjunct assistant professor at the University of the Incarnate Word Rosenberg School of Optometry, Dr. Chapman also enjoys working closely in training fourth-year extern students in current dry eye therapies, myopia management strategies, and practice management. She is a graduate of the University of Houston College of Optometry. gretnavisionsource@gmail.com

COOKIE MAGAZINE | July 2023

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COVER STORY ART.pdf 1 6/29/2023 3:58:03 PM

Cover Story

Seeing Eye to Eye

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f you’re engaged in the vision space, there’s no hiding from the inexorable inundation of the field by all things myopia. From an anxietyridden wave of research declaring the arrival of the myopia epidemic to the relentless churn of new products purpose-made to lay the condition low, one thing is obvious: Myopia management is unavoidable in modern eye care.

The door is open for ODs and MDs to work together on a new myopia co-management paradigm by Matt Herman

Unfortunately, there is something to the hype. On average, 30% of the world is myopic, and this number is expected to increase to a staggering 50% by 2050.1 Asia is a hotbed for the disease, with prevalences measured as high as Singapore’s 90%2 being echoed across the region.

Myopia rates are on the march worldwide. There is, however, a growing arsenal of tools and techniques to combat the condition. Cooperation between optometrists and ophthalmologists is a perennially thorny issue, but working together might represent the best way to take advantage of the latest myopia management marvels. There is a path through the co-management morass, and three top specialists from across the globe detailed what that might look like.

Even in the United States, typically considered one of the more tame regions of the world for myopia, rates almost doubled in the three decades between 1971 and 2004.3 And these trends have likely taken a turn for the exponential with the reduction in time spent outdoors and increase in near work engendered by the COVID-19 pandemic.

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The good news is that the world has responded. And dealing with the disease — at least in theory — has never seen more options in diagnostic and treatment modalities.

Axial length can be measured, tracked, and compared against increasingly representative normative databases. Pre-myopes can be identified more quickly and accurately than ever before.

Once identified, the roster of treatments for slowing or even halting the progression of the disease is long and varied. From orthokeratology and myopia control spectacle and daily contact lenses to pharmacological interventions like atropine eye drops, doctors worldwide are seemingly spoiled for choice.

But in the real world, the diagnosis and treatment of myopia is hitting a snag despite the abundance of options. Myopia as a condition teeters precariously on the fence between the traditional domains of optometrists and ophthalmologists.

Refractive error correction and screening have long been under the purview of ODs, and management of ocular disease ophthalmologists. As an ocular disease commonly treated with refractive correction, myopia can be seen as falling to both sides simultaneously. And the resulting tension is threatening to disrupt the promise of next-level outcomes for the millions suffering from myopia worldwide.

Kicking and screening One of the more critical aspects of myopia treatment in the modern era is screening for the disease. For Dr. Sun Chen-Hsin, a consultant at the National University Hospital (NUH) in Singapore specializing in pediatric ophthalmology and progressive myopia management, this is a key area where the division of labor is critical.

“The system is already in place and we should make use of that division of labor,” he related. “In Singapore, we are trying to get more optometrists in the community involved in caring for common eye diseases like cataract, glaucoma, dry eye, myopia… things

etc,” Dr. Sun continued. “The optometrist, as primary care provider, is able to screen and decide if the patient needs further treatment.”

Dr. Maria Liu, an ophthalmologistturned-optometrist and founder and chief of the prestigious Myopia Control Clinic at the University of California Berkeley, agrees. “In order to have the best [myopia] control outcomes, we need to identify the patient's risks and detect the problem as early as possible,” she said. “Early risk assessment and disease detection mostly lie with the optometrist to start collecting the patient's baseline axial growth profile.”

But while screening for refractive error is simple, identifying and isolating myopia as the cause is another beast. According to Dr. Sun, relying on simple refraction is not enough. For one, children with flatter corneas and high levels of axial elongation will go missed. “Those can be dangerous because they have a false sense of security. They may think, oh, my myopia is not too high, when in fact the eyeball is too long.”

Blaming the tools, not the carpenter Cycloplegic refraction is one avenue, but the need for eye drops prevents it from falling under the scope of practice for optometrists in many countries. And the results themselves are not without their faults.

There is one other option that both Dr. Sun and Dr. Liu see as critical for optometrists screening for myopia development and progression risk. “In terms of collaborative care in myopia progression, one key component is a biometer to measure axial length. All the complications from myopia stem from excessive elongation of [the eyeball],” Dr. Sun shared.

Dr. Liu also believes this to be a pressing need for optometrists. “At the current moment, a lot of doctors who claim to be a myopia control specialist do not even measure axial length,” she said.

So what’s keeping biometers out

of the hands of the optometrists on the front lines? For Dr. Liu, the issue lies with cost and industry lag and not optometrists themselves.

“The majority of optometrists are in private practice in smaller settings with smaller investments,” she lamented. “It requires the industry focusing on measuring axial length and early establishment of baseline [measurements] as important,” she said.

There are already ways cropping up to get these sorely-needed devices to optometrists who need them. Dr. Liu pointed to machines that don’t include royalty-laden IOL calculation formulae or other features beyond the bare essentials. Dr. Sun also described programs from myopia control product manufacturers that subsidize biometers in exchange for carrying that company’s wares.

Dr. Liu thinks insurance companies can play a large role, too. “Once we have insurance coverage for this kind of measurement, that would motivate doctors to actually invest in a biometer,” she said.

Handoff or hands off?

Once myopes have been identified, however, is where the picture begins to muddy. The overlap between ODs and MDs starts to widen — especially for MDs in private practice — and this is where the turf wars begin to rage.

It does not need to be so. Both Dr. Sun and Dr. Liu agree that there is room for all, starting with children where myopia is already high or developing quickly. Complications in these patients can come seemingly overnight, and a timely handoff from OD to MD is critical. “[With high myopes], early referral can make sure something like a small hole does not turn into a detachment or tear,” Dr. Liu related. “Something like that requires very close collaboration between optometrists and ophthalmologists.”

Dr. Sun believes that financial interest can only cause harm in this sense.

“Usually an optometrist and optician are the first point of contact. They get their first pair of glasses there, and they get followed up,” he started.

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Cover Story

“If a child is progressing and every six months the degree increases from 200, 300, 400, 500 and the optometrist just changes their glasses and does nothing else, this is doing the patient a great disservice,” he explained. “Unfortunately, there are people who do that for fear that if they refer to the ophthalmologist, the patient may not come back to them.”

This is a worrying trend, but Dr. Sun thinks that this is where supraprofessional bodies can play a role. “These high myopia complications can almost be eradicated completely if we have stringent referral guidelines — which we don’t,” he stated flatly. “Such guidelines could mandate that any child with any degree [of myopia] higher than a certain level must be referred and started on myopia treatment,” he further recommended.

Money mayhem In this way, a paradigm emerges where everyone wins. Optometrists use tools like biometers or cycloplegic refraction to screen myopic patients and monitor premyopes, referring them to ophthalmologists to look for retinal issues.

The next step is treatment, and this is the area where the financial conflict of interest is largest. The premium on myopia management and control products — like Ortho-K and myopia control spectacles or contact lenses — is high, and the lucre therein large, creating a tinderbox for competition and resentment.

Despite the potential for animosity, Dr. Sun and Dr. Liu believe there is massive room for collaboration, regardless of who is dispensing — and profiting. As a busy ophthalmologist in a highly regarded public healthcare system, Dr. Sun sees no reason for a break with the status quo with

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specialty contacts and spectacles.

“Spectacle lens, and to a certain degree contact lens fitting, is definitely something optometrists do better because of the volume they do every day,” he stated.

Fertile financial ground But that doesn’t mean that ophthalmologists need to be left out in the cold. As an optometrist, Dr. Maria Liu sees emerging treatment modalities as an opportunity for ophthalmologists as well. “ I do see ophthalmologists serving an increasingly important role in intervention as well,” she said. “Now with the availability of novel spectacles and low-dose atropine, I do see a lot of MDs being actively involved in myopia control intervention,” she continued.

And with the world digesting the LAMP2 study4 results for low-dose atropine in premyopes, a host of new patients could soon be heading to the ophthalmologist for treatment as well.

It doesn’t stop there either, according to Dr. Liu. Further down the line, the increase in myopia presents indirect opportunities for ophthalmologists.

“Refractive surgeons are becoming more and more supportive of myopia control because doing this makes patients a better candidate for refractive surgery,” she stated.

“The higher the prescription after myopia has stabilized, the more tissue needs to be removed in refractive surgery. If they ended up being a minus four, instead of, say, minus eight, for the same corneal thickness, they're more likely to be corrected without as many complications,” she explained.

In the end, though, despite the potential for symbiotic collaboration, there is still money involved in the private sphere, and there will still be the inevitable vitriol between ODs and MDs. Dr. Sun thinks, though, that keeping things in perspective is critical.

“Singapore is an extreme

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example — A vast majority of our population is myopic”, he reflected.

“There’s no shortage of people who can benefit from myopia treatment.

No matter how many thousands that we are seeing in our government hospital, we are really just scratching the surface,” he continued. “There’s a huge market out there and no one should fear that patients are being taken away from them.”

Building bridges As beneficial as the era of myopia control can be for both patients and doctors from both sides of the divide, there will always be work to be done to smooth this relationship. Some of this load can be borne at the top. Dr. Sun’s proposal for referral guidelines is one way to ensure cooperation is taking place at critical phases of disease progression.

Standardization of optometric education and certification is another oft-mentioned pathway for instilling more confidence in ophthalmologists with reservations about working with optometrists. Dr. Sun has called for more standardized postgraduate opportunities for ODs. “At the moment, there is no university level or even postgraduate level training available in Singapore, so they have to go overseas,” he said.

“When they get more training, they come back and those are the ones who have closer relationships with ophthalmologists in working together to provide care,” he related.

Inclusion in academic conferences for such highly-trained individuals is one way to ensure communication and consistency of message for myopia treatments for Dr. Liu. “In interprofessional and scholarly exchanges, we could have more vision scientists

and clinician-scientists on the optometry side with more podium time to talk about what is changing in terms of clinical evidence and animal models,” she proposed.

Dr. Glenda Aleman-Moheeputh, an optometrist and myopia specialist, believes strongly in the potential for our shared humanity to undergird strong professional relationships in myopia care. Even in the battleground of her native Florida, where legislation to remove the title of doctor from optometrists was recently introduced (and defeated), she sees the relationship as being stronger and more critical than ever.

“You need to drop the card, invite them to lunch, invite them to your office,” she suggested. “Let’s focus on building bridges. If you go in and break the ice and build a relationship with an ophthalmologist, they can be your biggest advocate,” she said.

And that’s exactly what Dr. Aleman-Moheeputh is doing with the nascent professional organization Women in Eyecare. She believes that uniting ODs and MDs along the axis of their shared humanity — and in this case, femininity — is one of the most potent ways for advancing patient outcomes through cooperation. “If we unite together, we can do bigger — and better — things,” she proclaimed. And for the growing multitudes of children worldwide at risk of, or already developing, myopia, this level of cooperation is the key to a future of clear sight.

Contributing Doctors Dr. Maria Liu is an associate professor at the UC Berkeley School of Optometry, and the founder and chief of the Myopia Control Clinic of UC Berkeley Eye Center. She received her bachelor's degree in clinical medicine from Peking University, her OD from Pacific University, and her PhD and MPH from UC Berkeley.

She is a world-renowned clinical researcher in the field of myopia and her expertise focuses on the impact of complex multifocal environments on emmetropization and myopia development, as well as novel optical and pharmaceutical treatments in myopia retardation

References 1. Holden BA, Fricke TR, Wilson DA, et al. Global Prevalence of Myopia and High Myopia and Temporal Trends from 2000 through 2050.

Ophthalmology. 2016;123(5):1036-1042.

2. Quek TP, Chua CG, Chong CS, et al.

Prevalence of refractive errors in teenage high school students in Singapore. Ophthalmic Physiol Opt. 2004;24(1):47-55.

3. Vitale S, Sperduto RD, Ferris FL. Increased prevalence of myopia in the United States between 1971-1972 and 1999-2004. Arch Ophthalmol. 2009;127(12):1632-1639 4. Yam JC, Zhang XJ, Zhang Y, et al. Effect of Low-Concentration Atropine Eyedrops vs Placebo on Myopia Incidence in Children: The LAMP2 Randomized Clinical Trial. JAMA. 2023;329(6):472-481.

marialiu75@berkeley.edu.

Dr. Sun Chen-Hsin is a clinicianengineer. He graduated from Johns Hopkins University in 2008 with a Bachelor of Biomedical Engineering and a Master of Science in Electrical and Computer Engineering in 2009. In 2013, he received a Doctor of Medicine (MD) from Duke-NUS Graduate Medical School. After completing his ophthalmology residency clinician-scientist training in 2019, he was accredited by the Specialists Accreditation Board as a specialist in ophthalmology by the Ministry of Health of Singapore. As he has special interests in managing progressive myopia in children and developing pediatric Ophthalmology medical devices, he developed a wearable device to track outdoor time and near reading. These are both important factors in determining myopia progression. He is also developing an ambulatory biometer to measure the elongation of eyeballs in children. This will allow precise monitoring of the myopia progression of children, optimizing their course of treatment. cfssch@nus.edu.sg

Dr. Glenda Aleman-Moheeputh, OD, received her Bachelor of Science degree in Vision Science and Doctor of Optometry from Nova Southeastern University (NSU). She has held the role of clinical liaison for Walmart Health Optometry in Florida from 2019-present. She currently serves as a Johnson and Johnson myopia management professional affairs consultant (PAC). She is an active advisor in the advisor committee AAOMC and is an advisor for Nevakar myopia specialists. She is the founder and CEO of iSmart Vision Care, located in Miami, Florida. In her practice, she specializes in providing multiple solutions for myopia management. And in her mission to fight the myopia epidemic, Dr. Aleman-Moheeputh has recently launched her new venture, OK Love Myopia Control Experts.

Beyond myopia management and educating patients, OK Love also offers consulting designed to educate fellow optometrists on various methods of implementing myopia control practices. She has lectured extensively nationally and internationally to contribute to educating others in the field of orthokeratology and myopia management in hopes of mitigating the myopia epidemic.

Drglenda.m@gmail.com

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Kudos |

WOMEN IN OPTOMETRY

WCO’s Dr. Sandra Block addresses today’s growing need to elevate the standard of care in myopia management by Brooke Herron The alarming rise of pediatric myopia is a global and multifaceted problem — and to help control the impending epidemic, optometrists need to know (and follow) the most current and effective management and treatment strategies.

Dr. Sandra Block, World Council of Optometry presidentelect, addressed the latest in mitigation, management, and treatment of pediatric myopia at a recent WCO Virtual Event, Myopia Management: Advancing the Standard of Care.

B

efore retiring, Dr. Sandra Block dedicated her career to pediatric optometry. Today, as the president-elect of the World Council of Optometry (WCO), she’s bringing her invaluable expertise to a global stage to help elevate the standard of care in myopia management.

According to Dr. Block, we need to recognize that myopia is not only a refractive state — but rather, a disease entity — that can cause vision loss through a number of different pathologies associated with moderate and high myopia. This includes posterior segment conditions like tilted disc, tessellated fundus, posterior staphyloma, thin choroid,

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macular degeneration, peripheral retinal degeneration, and vitreoretinal interface disease.

“Since we are now aware of the association of moderate and high myopia with these relatively common pathologies, it becomes more important for optometrists to look at myopia as a disease entity and consider myopia management to reduce the risk of developing these vision-threatening pathologies,” she said.

Keeping up with the latest evidence-based strategies In addition, the continued increase of myopia prevalence in younger

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children further contributes to the urgent need for eye care practitioners to get on the same page when it comes to management strategies.

“The profession is learning that the epidemic (almost pandemic) of myopia is continuing to grow,” said Dr. Block. “And it’s clear that there are many researchers providing evidence on how to address myopia management — and it’s imperative for eye care providers to stay on top of current research and how it impacts practice patterns.”

One way for optometrists around the world to stay up-to-date with the everevolving research is to participate in webinars, like the recent one held

by WCO. During these informative events, optometrists can glean clinical pearls that can be integrated into daily practice — all backed by experts and their personal experience.

“The WCO has realized that we, as global leaders for the optometric profession, need to communicate this research and rethink how we regard myopia,” explained Dr. Block. And it’s not just the optometric societies that are answering the call to halt myopia progression — the industry is also stepping up in areas of research and development, as well as in supporting education.

For example, the WCO, along with CooperVision, created their “Standard of Care Guidelines for Myopia Management” in 2021 to serve as an important resource for optometrists. This includes information on new tools developed for myopia mitigation, measurement, and management, supported by welldesigned studies that demonstrate successful methods to slow down the progression of the disease.

Embracing change through education According to Dr. Block, although eye care providers are slow to integrate change in their practices, it is happening — and the WCO is ready to support these efforts through education.

“From my perspective, change will occur faster as schools and colleges of optometry teach myopia management within the core curriculum,” said Dr. Block. “In addition, the number of webinars and articles that focus on the changing preferred practice guidelines, along with the education of the public from groups such as the Global Myopia Awareness Coalition (GMAC), will drive change at the level of patient care.

Educational programs will need to continue to be offered to help optometrists maintain the highest level of knowledge and skills to best treat their patients,” she continued.

Dr. Block hopes that viewers of the WCO Virtual Event

were convinced to at least update their perspective of myopia — and that’s away from the dated idea that myopia is a refractive error that can be corrected with simple optical lenses … to the reality that myopia is a disease entity that needs early detection, treatment, and follow-up.

“It’s our responsibility to educate patients and parents about lifestyle changes that can help lessen the impact, along with new and emerging tools to improve outcomes,” she said, adding that when it comes to pediatric eye care, parent involvement and awareness are imperative.

For example, parents should know what risk factors can be modified and which cannot, like genetics. “If a parent has myopia, that immediately increases the risk and that cannot be changed,” said Dr. Block. However, lifestyle changes can be made to help lower this risk, such as spending more time (at least 90 minutes per day) outdoors and less time on devices or doing other close work.

Eye exams also play a crucial role: Starting at age three and throughout school age, children should undergo multiple comprehensive eye exams. “We know that the eyes are still developing, and vision can change up to the age of 20,” she added.

“We need to ensure that our patients are offered the most effective and current treatments that could help maintain

a lifetime of good vision,” concluded Dr. Block. “Optometry is core to the diagnosis and treatment of myopia and I envision that the profession will step up to the call to action.”

For more information about myopia or to register for an upcoming webinar, visit https://myopia. worldcouncilofoptometry.info.

Contributing Doctor Dr. Sandra S. Block, OD, MEd, MPH, FAAO, FCOVD, is a Professor Emeritus at Illinois College of Optometry, Global Clinical Advisor and consultant to the Special Olympics Lions Clubs International Opening Eyes program, and cochair of the National Center for Children’s Vision and Eye Health.

Dr. Block received her OD degree in 1981 and Pediatric Residency in 1982 at the Illinois College of Optometry, where she is a faculty member. She completed her Master of Education at the National Louis University and her Master of Public Health from the University of Illinois, School of Public Health. She is a diplomate in Public Health and Environmental Vision at the American Academy of Optometry and a Distinguished Fellow of the National Academy of Practice. She sits on the Prevent Blindness Board of Trustees and recently joined the VISION 2020 Board of Directors. Dr. Block has been a consultant to the Special Olympics Lions Clubs International Opening Eyes program since 1995 and has been instrumental in developing the vision program globally. Her interests lie in primary care for children and persons with disabilities, as well as diagnosis and treatment of visually related learning problems as well as public health issues facing the equity and quality of eye care delivery.

She has authored numerous publications and conducted presentations worldwide. In November 2021, she was elected as the WCO President-Elect. Prior to this, Dr. Block served on WCO’s Board of Directors as the Public Health Committee Chair.

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Innovation |

OPTICS TECH

Specs and Control Embracing the promise of myopia control-specific spectacles

by Ben Collins

With the global myopia epidemic showing no sign of slowing up any time soon, innovative and progressive treatments could prove crucial in tackling the growing problem. Among such promising solutions are myopia control-specific spectacles. Being relatively non-invasive and devoid of complications, these specs prove very popular among myopia sufferers — especially children, who are unfortunately most vulnerable to this condition.

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M

yopia control spectacles are eyeglasses designed to slow down or halt the progression of myopia in children and adolescents. These glasses feature specialized lenses that work by altering the way light enters the eye, reducing the amount of strain placed on the eye's focusing mechanism.

The lenses used in myopia control spectacles can take several forms, including multifocal lenses, extended depth of focus lenses (EDOF), and peripheral defocus lenses.

Where in the world?

Myopia control glasses are gaining popularity worldwide, and they are particularly popular in East Asian countries, such as China, Taiwan, Hong Kong, and Japan — where myopia rates are among the highest in the world.

In East Asia, it is estimated that as many as 80% of children may develop myopia by the time they reach adulthood. This has led to extensive

research and development of myopia control options in these countries, including myopia control spectacles.1 One reason for the popularity of myopia control glasses in East Asia is the recognition of the potential long-term negative effects of myopia.

Studies have linked high myopia with a range of ocular disorders, such as glaucoma, retinal detachment, or even blindness in later life.2 With the rise of myopia in East Asian countries, the emphasis is on early identification and treatment.

Will the West follow?

In countries like Australia, Canada, the United Kingdom, and the United States, myopia control glasses are gaining recognition and more research is being conducted on the treatment options and long-term effects of the condition. However, there is a need for increased awareness about myopia control, not only among the general public but also among healthcare professionals, both in East Asia and worldwide.

With the global prevalence of myopia on the rise, it is likely that the use of myopia control glasses and other treatments aimed at slowing down its progression will become more common, including in regions where it is currently less widespread.

Promising a clearer future Several brands offer myopia-control spectacles. Here are a few leading ones, and a contact lens-based device for comparison:

MiYOSMART (Hoya Vision Care, Tokyo, Japan):

MiYOSMART lenses use defocus

incorporated multiple segments (DIMS) technology. The lenses have a series of small grooves that create a slightly blurred image on the peripheral retina, which can slow down the elongation of the eye.

MyoVision Pro (ZEISS, Jena, Germany): MyoVision Pro

lenses are designed to reduce eye fatigue and prevent further progression of nearsightedness. The lenses work by incorporating a lens design that causes images on the peripheral retina to be slightly blurred, much like the MiyoSmart lenses.

Stellest (Essilor, Charenton-le-Pont, France):

Stellest lenses are the result of more than five years of research and development. They use a specific optical design that can redirect the incoming light and blur it onto the peripheral retina. This helps to limit myopia by lessening the strain on certain parts of the eye.

MiSight (CooperVision, California, USA): MiSight

lenses from CooperVision are soft contact lenses worn during the day.

They are designed with concentric rings to create a diffusing effect on the peripheral retina, which reduces the tendency of the eyes to lengthen.

Attitude (Shamir, Shamir, Israel): Attitude lenses use

what the company calls EyePoint technology. [Editor's Note: In August 2022, Essilor Luxottica completed its acquisition of Shamir.] This offers additional power to the lens that is designed to shift the focal point away from the retina's central point, which plays a major role in the elongation of the eyeball.

So, are myopia control spectacles right for your patients?

Myopia control spectacles are typically prescribed for children and teenagers who have been diagnosed with myopia and who show signs of rapid progression or have one or both parents with high myopia. The goal of these glasses is to slow down the rate of myopia progression, enabling the child's eyes to develop normally.

It is important to note that while myopia control spectacles have shown promising results in some studies,3 they are not a cure for myopia. These glasses may work differently for each individual, and users might experience a minor adjustment period.

Other vision therapies, like behavioral and environmental modifications, are often used in conjunction with myopia control spectacles to achieve better results and reduce the need for stronger prescriptions in the future.

References 1. Ha JJ, He M. Preventing myopia in East Asia. Community Eye Health. 2019;32(105):13-14.

2. Williams K, Hammond C. High myopia and its risks. Community Eye Health. 2019;32(105):5-6.

3. Rappon J, Chung C, Young G, et al. Control of myopia using diffusion optics spectacle lenses: 12-month results of a randomised controlled, efficacy and safety study (CYPRESS). Br J Ophthalmol. 2022;bjophthalmol-2021-321005. [Online ahead of print.]

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Enlightenment |

MYOPIA MANAGEMENT

A Vision for Vision

New Zealand’s trailblazing optometrist proves that teamwork makes the dream work

by Joanna Lee

A visionary optometrist, Dr. Jagrut Lallu has spearheaded the establishment of New Zealand's first myopia management clinic. Through his pioneering efforts, he emphasizes the importance of fostering a close collegial relationship between optometrists and ophthalmologists to combat myopia collectively. Dr. Lallu shared with COOKIE Magazine his insights for cultivating this collaborative approach to myopia management.

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D

r. Jagrut Lallu’s journey began during his final year as an optometry undergraduate, when he predicted that myopia management would become an integral part of every practice.

“The more you give, the more you learn and get. It's really an easy philosophy,” he said, sharing one of the key elements to successfully pioneering New Zealand’s first myopia management clinic in 2009. Below, he shared his tips for anyone who wishes to emulate this model of myopia management.

A clear vision for the future From the get-go, Dr. Lallu’s vision was very clear— he wanted to set up an Ortho-K and myopia management clinic. Back then, myopia management was not a priority, and Ortho-K was considered risky.

When he was first setting up his myopia management clinic, he reached out to over a hundred local

ophthalmologists and 300 sports clubs, informing them about the new clinic concept. Fortunately, they were all receptive to his ideas. Pediatric ophthalmologist Dr. John Dickson and a group of ophthalmologists at the Hamilton Eye Clinic were particularly supportive from the very beginning, even agreeing to accommodate his patients and conduct axial length measurements at their facilities.

Today, the thriving myopia management clinic has been instrumental in bringing together a community of optometrists and ophthalmologists in the Hamilton area. It sees many referrals from its direct optometric competitors, the local hospital, as well as private consultants and specialists.

“How the model works is that either an optometrist or an ophthalmologist would refer patients to our myopia management clinic for expert opinions," explained Dr. Lallu.

“We would then write back to the referring practitioner following the development of a treatment plan.

In cases where the referrer is an optometrist and [the patient] requires spectacle correction, we recommend that they fulfill that need, and then we proceed with co-managing the patient's myopia. In addition, we also receive referrals from general medical practitioners who seek our review on the next best steps for myopia management.”

Building a strong practice through co-management How does one even start the ball rolling to set up a myopia management clinic or community?

He said the most important thing is to start doing something. “Do one thing a day, you'll eventually get there and things will just get better,” shared Dr. Lallu. “Reach out for mentorship and support, and ask for help from people like myself who are happy to share everything,” he added. ”It’s all about creating a mutually

beneficial agreement. When we were initially setting up the clinic, we asked if we could have axial lengths measured by a local ophthalmologist, and they initially offered to do it for us free of charge," Dr. Lallu shared.

"However, instead of accepting their generous offer, we proposed a different approach: ‘Let's pay you a fee.’ This model has been quite successful because it allows the ophthalmologist to earn additional income while building a relationship with the optometrists."

Seek opinions, build trust “Whenever there's a tricky case, you might want to seek another practitioner’s opinion and bounce ideas off each other,” Dr. Lallu said.

This exchange of knowledge and ideas enhances patient care and promotes a comprehensive approach to managing complex cases.

Sometimes it could also be as simple as sharing meals together. “Generally, on an annual basis (excluding the COVID period), we would go out to dinner with all of the 15 or 16 ophthalmologists in our area, as well as registrars at the public hospital,” he shared. “What's nice about that is

we get to put faces to names of the people we work with, either through phone or via email. This helps create a sense of collegiality, building relationships that are independent of roles and responsibilities. These social gatherings allow us to build trust and camaraderie.”

“Trust is not difficult to build if you go with an open heart,” he enthused.

“Just be honest. If you don't know how to do something — say, can I pay you to do an axial length for me?

Can I take you to lunch? Can we go to dinner? Can you educate me on this?

What are your views?”

Being honest and asking for help and support from colleagues greatly contribute to establishing trust and rewarding professional relationships.

A rewarding mutual partnership Apart from the above factors, Dr. Lallu mentioned that having an organization like the New Zealand Corneal and Contact Lens Society — founded in 1958, the oldest in the world, and has ophthalmologists and optometrists as its members — had also paved the way for fostering “a very strong relationship” between the two professions.

“I realized it's not necessarily like that in some other countries,” he said.

“And that's okay. However, I think our colleagues very quickly realized that it is important to get along and work together where possible.”

It’s an enjoyable two-way relationship. The mutually beneficial partnership can yield numerous referrals to both private ophthalmologists and the public healthcare system. “When you have a good relationship with optometrists, you will see a substantial number of cataract surgeries and referrals to subspecialty areas, creating a symbiotic environment,” Dr. Lallu noted.

Furthermore, mini-myopia management clinics have been set

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Enlightenment |

MYOPIA MANAGEMENT

up throughout the country — only confirming the fact that this model for co-managing myopia works.

Personal rewards and a sense of fulfillment Dr. Lallu said his greatest satisfaction stems from the outcomes of effective patient care through customized myopia treatment plans. He shared, "One of the most rewarding things is seeing these children grow up, especially those patients who have been under our care at a very young age, and who are now in their 15th year of myopia management. We've had a lot of wins,” he shared.

However, he also acknowledged the challenges posed by delayed treatment. “It’s better to treat them when they’re less myopic. Why wait until a patient becomes -5.00 before you refer them, when we can intervene at -1.00? But it’s a continuous process of learning progress. And we’re getting there.”

And he’s just getting started…

Dr. Lallu's next goal is to help make atropine a publicly funded prescription to help reduce the cost to the public. He also continues to lobby for a minimum standard of care for myopia management.

“There’s been too much evidence for the benefits of managing myopia, and there’s no reason why any practitioner in the country can’t get

access to these products that work,” he explained.

“Now’s the time for the government to do this and if they do this first, it will pave the way for other countries to continue this message,” he added.

“This can actually change the way we look after myopes.”

Dr. Lallu is also fully supportive of his colleagues in their optometric initiatives, among which is Amanda Edgar, Senior Lecturer of Learning Spaces Innovation from the Faculty of Deakin Learning Futures. She built a virtual clinic platform that allows students from across the globe to participate and learn about various topics in the fields of optometry and ophthalmology.

In addition, they are looking at a few clinical trials related to specific products connected with red light therapy. Besides working with different countries and supporting them in their regulatory approvals, Dr. Lallu is investigating prospective research and retrospective analyses, thanks to a large accumulation of data from long years of myopia management and through products such as MiSight® (CooperVision, California, USA), Forge Ortho-K (EyeSpace, Worcestershire, England), and MiYOSMART (Hoya Vision Care, Tokyo, Japan) lenses and methods of combination atropine treatments and orthokeratology. They are hoping to publish findings that might benefit a wider audience.

Dr. Jagrut Lallu (third from left) and the Rose Optometry team in Hamilton, New Zealand

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They also have an education arm to educate and support practitioners who come in to learn about various subspecialties.

“It’s about seeing what you can do to get involved,” Dr. Lallu emphasized.

"By sharing your knowledge and experiences, you can foster personal growth and achieve success in this field. If you don't know something, just ask someone because 99% of all of the eye care professionals are actually happy to lend a helping hand,” he concluded.

Contributing Doctor Dr. Jagrut Lallu graduated with honors and a host of undergraduate awards from the University of Auckland in 2009. That same year, he began working for Visique Rose Optometrists – Home of the Rose K lens in Hamilton, New Zealand. He has a special interest in keratoconus and other irregular cornea diseases and orthokeratology, including hyperopic, astigmatic, and myopia control with Ortho-K. He relished learning the art of contact lens fitting from his colleagues Paul Rose and Peter Walker. In late 2009, he set up the first myopia control clinic in New Zealand devoted to evidence-based methods for management. He now owns Rose Optometry and Innovatus Technology, which provides services to practitioners and manufacturers for rigid contact lens design through topography.

In 2017, he received his Master’s Degree with honors for specialty contact lenses and orthokeratology from the University of Auckland.

He has co-authored a textbook entry for a chapter on corneal topography and has created online virtual learning modules with the Deakin University. He is a clinical Senior Lecturer at the Deakin School of Optometry and is currently publishing a variety of topics related to orthokeratology and machine learning. jlallu@roseoptom.co.nz

EssilorLuxottica and WSPOS Once Again Collaborate to Advance Education of Global Myopia Management

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s part of EssilorLuxottica and the World Society of Paediatric Ophthalmology and Strabismus’ (WSPOS) long-standing efforts to advance evidence-based myopia education globally, WSPOS’ independent medical education program content on myopia management is now fully available on EssilorLuxottica’s openlearning platform, Leonardo. This aims to provide the vision care industry with learning content designed and taught by industry experts. This collaboration will contribute to further educate and help eye care professionals successfully integrate myopia management into their practice.

This year, the program also features a digital supplement, three e-learning modules, and three 60-minute webinars,

which will also be available on Leonardo.

EssilorLuxottica has partnered with WSPOS every year since 2020 in a commitment to share knowledge and insights on myopia control interventions, including Essilor Stellest actively participating in their annual congresses and sub-specialty symposiums.

EssilorLuxottica is also a gold-level supporter of the WSPOS independent medical education program.

“We are pleased to continue our longstanding partnership with WSPOS, an organization that shares our vision to contribute to better vision for children.

As part of our partnership to advance myopia education, the WSPOS medical education program content on myopia management is available globally for

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The World Society of Paediatric Ophthalmology & Strabismus (WSPOS) has issued its Myopia Consensus Statement 2023, concluding there is “sufficient evidence to warrant the adoption of myopia prevention and control measures in clinical practice in children with progressive myopia of childhood.”

eye care professionals through our learning platform, Leonardo,” said Olga Prenat, head, Medical and Professional Affairs and Vision Care Education, EssilorLuxottica. “We look forward to accomplishing more together this year to contribute to the widespread adoption of myopia management.”

Dr. Ken K. Nischal, WSPOS cofounder and division chief, Pediatric Ophthalmology, Strabismus, and Adult Motility, professor of ophthalmology at the University of Pittsburgh, School of Medicine, said: “Myopia management is an extremely important component of WSPOS’s public health initiatives and we are delighted to have support from EssilorLuxottica for our Myopia IME.”

Industry Update

New Developments Show Eye Care Community Embracing Myopia Management wo recent publications indicate that the ophthalmology community is more broadly embracing myopia control and management.

Industry Update

lens myopia control interventions, including increased prescribing of CooperVision MiSight® 1 day, alongside other management options such as orthokeratology, specialized spectacle lenses, and atropine,” said Elizabeth Lumb, director of Global Professional Affairs, Myopia Management, CooperVision.

Independently, Eye & Contact Lens, the ophthalmological peer-review journal of the Eye and Contact Lens Association, has published a paper affirming the corneal health of children who wear soft contact lenses in comparison to adult wearers.

The WSPOS guidance is based on studies that have demonstrated both statistical and clinical significance in the effectiveness of slowing myopia progression. In referring to MiSight 1 day, the authors share highlights from the landmark long-term, international MiSight 1 day clinical trial to convey its efficacy, including children aged eight to 12 who showed a 59% reduction in spherical equivalent refractive error over a three-year period, compared to single vision contact lenses.

“We applaud the WSPOS and Eye & Contact Lens decisions to publicly address these topics since myopia progression in children is one of the greatest ocular health issues of our lifetime. Ophthalmologists worldwide are taking a heightened interest in contact

In their Eye & Contact Lens paper, Incidence of Corneal Adverse Events in Children Wearing Soft Contact Lenses, myopia experts Mark Bullimore and Kathryn Richdale noted the growing interest in soft contact lens prescribing for children, in part due to specific

use for slowing myopia progression.

The investigators analyzed seven prospective and two retrospective peer-reviewed studies published from 2004 to 2022 on contact lens-related complications in children, totaling more than 6,000 years of wear among 2,781 patients.

They concluded that children wearing soft contact lenses are at no greater risk than adults for microbial keratitis, and their incidence of corneal inflammatory events appears to be markedly lower.

“This move echoes similar steps taken by the global eye health community in recognizing that we must treat myopia in children as early as possible, and at lower levels, to have the greatest long-term impact. It is particularly encouraging to see an increasing number of eye care-related professions recognizing the need to bring awareness to increasingly available evidencebased clinical interventions. Active participation by ophthalmologists is critical and we are encouraged about the gain being made there,” concluded Lumb.

COOKIE MAGAZINE | July 2023

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Enlightenment |

MYOPIA TRENDS

Heeding the Wakeup Call

Through collaboration and effective “I'm very concerned with myopia because it is definitely progressing. have a lot of evidence of that," management strategies, eye care We said Dr. Elise Kramer, a residencytrained optometrist in Miami and professionals can combat the an expert in specialty contact lens design and fitting. global myopia epidemic

by Jena Passut

Myopia is on the rise worldwide, with the International Myopia Institute estimating that nearly half of the world will be myopic by 2050.1 Optometrists and ophthalmologists play crucial roles in the management and treatment of myopia, and their collaboration is essential for optimizing patient outcomes.

“Fifty percent of Asian children are myopic, and we are going to reach that 50% here eventually if we don't slow it down. So, I’m a huge proponent of myopia management and control. It is very relevant not just in my practice, but all over the world,” she continued.

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Enhancing comanagement practices for improved patient outcomes

n recent years, myopia has reached epidemic proportions in many parts of the world, particularly in East Asia. However, studies1 indicate that myopia is also increasing at an alarming rate in other regions, including North America, Europe,

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and Australia. This global trend has prompted a shift in the approach to myopia management, focusing on proactive interventions to slow down its progression and reduce associated risks.

COOKIE MAGAZINE | July 2023

Traditionally, optometrists have been primarily responsible for prescribing

corrective lenses to improve visual acuity, while ophthalmologists have focused on surgical interventions and the management of ocular diseases.

However, the management of myopia requires a comprehensive and collaborative approach involving both specialties.

“Unfortunately, although the rise in myopia rates has been welldocumented in scientific literature, many practitioners are not fully aware of the extent of the problem and have little time to focus on it. Addressing these knowledge and time gaps is essential for promoting the adoption of effective myopia management strategies,” Dr. Kramer said.

Beyond traditional singlevision interventions Despite the increasing awareness of myopia as a public health concern, many practitioners still primarily prescribe single-vision interventions, such as glasses and contact lenses, without implementing additional strategies.

that practitioners’ job satisfaction goes up when they practice myopia control, and it is financially viable for their business,” Prof. Wolffsohn added.

Challenges in adopting certain myopia control strategies

Despite the availability of effective strategies, there are various reasons why some practitioners have been hesitant to adopt them “A lot of practitioners are overloaded universally. with patients. Some work in big Concerns corporate enterprises and they get related to patient scheduled for six patients an hour,” compliance, she added. “A second reason is cost, and long— Prof. James Wolffsohn lack of resources or availability of term efficacy equipment or products.”

Several strategies have been cited have been shown to effectively slow as barriers to implementation.

Prof. James Wolffsohn, a UK-based down the progression of myopia Additionally, limited training and professor of optometry and co-author and reduce associated risks. These access to specialized equipment or of a recently published study2 on include orthokeratology (corneal technologies necessary for certain myopia management, agrees that reshaping contact lenses), multifocal interventions may also hinder practitioners need more resources, contact lenses, atropine eye drops, widespread adoption. in addition to time, when it comes to and behavioral modifications myopia management. such as increased outdoor time "If practitioners don't have the time or and reduced near-work activities. resources to do myopia management “It is less of a knowledge gap (and Optometrists and ophthalmologists in their practice, they should comore about) making products need to be knowledgeable about manage with another optometrist or available to them and encouraging these strategies and consider their an ophthalmologist who does myopia them to engage,” he said. incorporation into their clinical management," Dr. Kramer advised. practice.

“The more people understand how Ophthalmologists important this is, the more of a may have “Many myopia difference we can make.”

“I'm very concerned resources control with myopia because it approaches have optometrists Navigating codon’t, and vice is definitely progressing. been shown in management challenges versa. robust clinical We have a lot of and opportunities trials to slow the evidence of that.”

“It’s a very good progression of Apart from the co-management collaboration myopia (compared practices, awareness, and adoption — Dr. Elise Kramer because to wearing of myopia management strategies, obviously surgery a traditional it is worth mentioning a few other is out of the scope of my practice,” Dr. single-vision correction) by 40% to critical issues related to myopia Kramer said. “Open communication 60% in children, on average," Prof. crossover between optometry and about what we're doing for this Wolffsohn said. “Natural eye growth ophthalmology patient and how we're managing the still occurs, but the child should end case together is essential to have.” up less shortsighted than they would Early Detection and Screening have been and their risk of visually “Eye care professionals working impacting complications later in life Timely detection of myopia is crucial together always benefit patients due reduced.” for implementing initiative-taking to more joined-up care,” noted Prof. interventions. Optometrists and Wolffsohn.

An added bonus? "Our survey shows ophthalmologists could collaborate “Single-vision spectacles and contact lenses are well established for correcting myopia (allowing children to see clearly) and are very safe, but research shows they do not slow progression,” Prof. Wolffsohn explained.

“Single-vision spectacles and contact lenses are well established for correcting myopia (allowing children to see clearly) and are very safe, but research shows they do not slow progression.”

COOKIE MAGAZINE | July 2023

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Enlightenment |

MYOPIA TRENDS

to establish standardized screening protocols, especially for high-risk populations such as children with a family history of myopia or those exposed to prolonged near work.

Patient Education Educating patients and their families about myopia, its progression, and the available management options is vital. Practitioners can develop educational materials and counseling strategies to empower patients to take an active role in managing myopia.

“We're more focused on the education part rather than the implementation, at least in the first visit," Dr. Kramer said.

“Especially if it’s a child's first eye exam, those are some of the most challenging because not only do you have to diagnose them, but you also must explain that this condition is progressing and that now we need to do another treatment. It can be an overwhelming conversation.

There's a lot of new information, and sometimes you have to bring parents back for that,” she shared.

"We have a lot of educational materials. We give them resources where they can take the time to discuss these things with a partner or spouse or significant other, and then come back and make a decision,” she added.

Research and Innovation Continued research and innovation are essential for advancing the field of myopia management. Optometrists and ophthalmologists can collaborate on research projects, clinical trials, and the development of innovative technologies or treatment modalities to further improve patient outcomes.

"Myopia control treatments are relatively new, so while the rate of them being prescribed is increasing, there is still a long way to go for a substantial adoption and practice will always lag attitudes,” Prof. Wolffsohn added.

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Advancing myopia management for a clearer future The crossover between optometry and ophthalmology in the management of myopia is vital for improving patient outcomes in an era of increasing myopia prevalence. By embracing a collaborative approach, optometrists and ophthalmologists

can work together to enhance their understanding of myopia, adopt effective management strategies, and provide the best possible care for their patients. It is through interdisciplinary collaboration, research, and education that we can tackle the global challenge of myopia and ensure a clearer future for patients.

References 1. Holden BA, Fricke TR, Wilson DA, et al. Global Prevalence of Myopia and High Myopia and Temporal Trends from 2000 through 2050. Ophthalmology. 2016;123(5):1036-1042.

2. Wolffsohn JS, Whayeb Y, Logan NS, et al. IMI - Global Trends in Myopia Management Attitudes and Strategies in Clinical Practice - 2022 Update. Invest Ophthalmol Vis Sci. 2023;64(6):6.

Contributing Doctors Dr. Elise Kramer is a residencytrained optometrist in Miami, Florida, who specializes in ocular surface disease and specialty contact lens design and fitting.

Her doctorate degree was awarded in optometry from the Université de Montréal in 2012. During her fourth year, she completed her internship in ocular disease at the Eye Centers of South Florida and went on to complete her residency at the Miami VA Medical Center.

Her time there included training at the Bascom Palmer Eye Institute, the nation’s top eye hospital.

After her residency, Dr. Kramer became a fellow of the Scleral Lens Education Society (SLS) and now serves as the treasurer for the SLS. Dr. Kramer is a member of the American Optometric Association and the International Association of Contact Lens Educators, as well as a Fellow of the American Academy of Optometry and the British Contact Lens Association. She is also the Delegate of International Relations for the Italian Association of Scleral Lenses. Dr. Kramer has published several important articles and reviews and participates in clinical research trials. She enjoys lecturing all around the world in several different languages about ocular surface diseases and specialty lenses.

COOKIE MAGAZINE | July 2023

elise@miamicontactlens.com

Prof. James Wolffsohn, a professor of optometry at Aston University since 2000, former Deputy Executive Dean for Life Sciences and then associate pro-vice chancellor, is the head of the School of Optometry at the university. Prior to his appointment at Aston University, Prof. Wolffsohn was a Clinical Research fellow at the University of Melbourne in Australia. His main research areas are the development and evaluation of ophthalmic instrumentation, contact lenses, intraocular lenses, and the tear film. He is also a National Teaching Fellow, has published more than 280 full peerreviewed papers, and presented at numerous international conferences. He is the academic chair of the British Contact Lens Association, having been a past president, was a harmonizer and sub-committee chair for TFOS DEWS II, and was chair of the BCLA Contact Lens Evidencebased Academic Reports (CLEAR).

He is the International Myopia Institute’s chief scientific officer and was joint-chair of their white papers. j.s.w.wolffsohn@aston.ac.uk

Industry Update

First-Ever Myopia Action Month Announced for September 2023

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yopia Profile, a clinical myopia management information center for eye care professionals (ECPs), announced its launch of Myopia Action Month to channel myopia awareness into action. Taking place in September this year, the inaugural event will bring four weeks of global education, industry collaboration, and encouragement to ECPs to empower them to take effective action against the disease. The global initiative is sponsored by founding partners CooperVision, EssilorLuxottica, and Johnson & Johnson Vision.

“In the past few years, we have witnessed huge growth in myopia management research awareness,

industry innovations, and education, and yet we continue to see reports of single vision corrections being predominantly prescribed to children with myopia,” said Dr. Paul Gifford, director at Myopia Profile. “Our mission is to accelerate the uptake of myopia management in clinical practice. We saw the need for something more — a new strategy to empower myopia awareness into myopia action.”

Myopia Action Month will focus on supporting ECPs in building their clinical capacity with community support and accountability through an ambitious instructional program.

Educational materials and resources will be accessible through Myopia Profile’s unique and extensive digital ecosystem.

New SightGlass Vision Research Reinforces Myopia Control Efficacy and Safety of DOT Spectacle Lenses

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ightGlass Vision announced positive outcomes of multiple studies designed to evaluate the performance of its Diffusion Optics Technology™ (DOT) spectacle lenses, which are designed to slow the progression of myopia in children. The good news was presented at the 2023 ARVO Annual Meeting in New Orleans in April this year.

a child develops and is most rapid before preadolescence, deriving an age-adjusted measure is valuable for clinicians and researchers. Physiological AL growth was determined based on age-matched emmetropic eye growth data from the Orinda Longitudinal Study of Myopia, then compared to AL growth observed in the original three-year CYPRESS study.

Most prominent was the reporting of 42-month data from the company’s pivotal CYPRESS study extension.

Results reinforced the safety and efficacy of Diffusion Optics Technology spectacle lenses in children aged six to 10 at the study’s start. The latest investigation re-enrolled 98 participants from the original three-year, doublemasked, randomized, multi-site clinical trial to generate six additional months of data. Outcomes again demonstrated statistically significant improvements in axial length (AL) and cycloplegic spherical equivalent refraction (cSER) between the test and control groups.

Children in the test lens group showed 0.23 mm (73%, p=0.003) less pathological AL change than the control group (test: 0.08 ± 0.06 mm; control: 0.31 ± 0.05 mm).

Separate work calculated ageindependent myopia AL growth to evaluate DOT spectacle lens efficacy.

Because AL growth occurs even in persistently emmetropic eyes as

In addition to the featured CYPRESS presentations, SightGlass Vision and its research partners [displayed] several scientific posters at the meeting. A study from the Centre for Ocular Research & Education (CORE) showed that DOT

“The extensive and rigorous science we [communicated] at ARVO 2023 demonstrates the depth of our commitment to advancing myopia control, while also building additional confidence in the efficacy, safety, and overall performance of Diffusion Optics Technology spectacle lenses,” said Andrew Sedgwick, CEO of SightGlass Vision.

“For each week of the event, in partnership with event sponsors, we will feature new video resources, themed action plans, and specific educational and practical materials to support ECPs at any level to grow their myopia action plans and management strategies,” said Dr. Kate Gifford, director at Myopia Profile. “We are also launching challenges, online courses, downloads, and more to make the month engaging, inspiring, and most of all empowering for ECPs to take myopia action.”

More information on Myopia Action Month, including how to register, will be published www.myopiaprofile.com in the coming months.

Industry Update

spectacle lenses have no significant effect on accommodative lag after short-term wear. Work from Indiana University suggests that Diffusion Optics Technology contrast-reducing microdots do not limit high-quality spatial details and good visual performance, while another Indiana investigation concludes that wearers are unlikely to notice substantial contrast decreases when looking through the spectacle lens treatment zone.

A SightGlass team also examined the effect of social restrictions during the COVID-19 pandemic on myopia progression in North American children who participated in the CYPRESS study.

Spectacle lenses with SightGlass Vision DOT use thousands of micro-dots to softly scatter light to reduce contrast on the retina, a unique mechanism of action to control myopia progression in children.

Over the last 18 months, this patentprotected technology with clinically proven efficacy made its commercial debut in several markets, including China, the Netherlands, and Israel, as well as through preliminary market trials in other countries. The company operates as a joint venture of CooperCompanies and EssilorLuxottica.

COOKIE MAGAZINE | July 2023

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Conference Highlights |

APOC 2023

Empowering Optometry in India

APOC 2023 highlights outreach programs, regulatory developments, and improved eye care

by Brooke Herron

As the most populous country in the world, India faces distinct challenges and opportunities in providing optometric care. At the 23rd Asia Pacific Optometric Congress (APOC 2023), held from June 2 to 4 in Gurugram, practitioners from Asia Pacific and beyond addressed developments in eye care, including the benefits of community outreach and the changing regulations surrounding optometry in India.

and we learned a lot about outreach programs, what vision therapy adds to optometric practice, and the factors associated with regulating the profession.

Legislating optometry’s independence in India Although there are many challenges for Indian optometrists, the main challenge lies in regulating the profession, explained Dr. Subodh Dixit, co-chairperson of APOC 2023 and the national president of the Indian Optometric Association.

Further issues, like lack of standardized nomenclature (i.e., optometrist, optometrist technician, etc.), also need to be addressed, said Dr. Dixit.

Fortunately, he shared that the Indian Optometric Association is diligently working toward the betterment of optometry in India: “The priority of the Indian Optometric Association is to uplift our profession … where the practice of optometry is totally independent and they are not under supervision.”

And based on the chatter at APOC surrounding optometry’s regulation in the country, this will be a hot topic in India until it's passed.

Integrating vision therapy and optometry Dr. Cathy Stern, one of the keynote speakers at APOC 2023, is an optometrist and adjunct faculty at the New England College of Optometry (NECO) in Massachusetts, USA. She works as a behavioral optometrist, helping children and adults who have visual issues that are not necessarily eyesight-related through vision therapy and vision rehabilitation.

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n many countries around the world, optometry remains an unregulated profession. However, in India, things are changing — thanks to the National Commission for Allied and Healthcare Professions Bill, which will regulate and recognize optometry as a separate healthcare profession through standardized education and practice.

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Of course, this doesn’t come without hurdles — providing eye care to 1.4 billion people is not an easy feat.

Therefore, community outreach and continued education and integration remain key assets in providing care to underserved populations. So, at APOC 2023, we made it COOKIE magazine’s mission to speak with as many optometrists as possible —

COOKIE MAGAZINE | July 2023

“Vision therapy, to me, is really an extension of everything that we do,” she said. For example, when Dr. Stern examines a patient, she includes tests that reveal how they process visual information.

“Can they move their eyes properly, like to read from a book? Can they work their eyes together so that they don't get tired or get headaches or

see double? Can they understand what they're looking at and make a response in a reasonable or appropriate amount of time? If I throw you a ball, are your hands going to be there at the right time to catch it? It’s your visual system that’s directing that action,” she explained.

“If we’re finding that type of vision with a patient, I can ask good history questions and they may even tell me there are certain things that they struggle with. Then I do a few tests — more than just a basic eyesight test — and I can often see just from that that maybe something is going on,” said Dr. Stern.

Correcting some of these issues could simply mean prescribing certain lenses that help patients focus their eyes better. In other cases, Dr. Stern explained that they do active vision therapy.

“They may come to the office once or twice a week and work on certain activities for maybe an hour,” she explained. This can help these patients better develop these skills, along with practice techniques to do at home. On average, she said that she works with patients for six to nine months.

Go where the people are Dr. Rajeev Prasad, vice president of the Asia Pacific Council of Optometry, has taken direct action to help address unmet needs in India through

community outreach programs — and he’s gone about it efficiently.

Rather than asking underserved populations to come to them, they’ve set up clinics during India’s holy celebrations, which are attended by hundreds of thousands of people.

For example, in 2019, more than 500,000 people were screened and 150,000 received free prescription glasses during their trip to take a dip in the Ganges River over a major public holiday. Further, he shared that all the glasses were made on-site and provided to patients on the same day.

Following this event, he orchestrated a second outreach project in 2021 during COVID. “It was a challenge, but it was a wonderful experience … it really showed how a pair of glasses can give happiness,” said Dr. Prasad.

“There are people who just can't see well, and they also can't afford to go to eye care practitioners to get the services or to pay for a pair of glasses, so that was touching and absolutely amazing.”

Generosity across the (color) spectrum Drawing inspiration from Dr. Prasad’s outreach programs was Mr. T.J. Waggoner, co-founder and CEO of Waggoner Diagnostics, who gave complimentary color vision tests to every delegate in attendance at APOC 2023. This generosity — about 300 Waggoner Computerized Color Vision

Tests (CCVT) were distributed — was not only about doing something good, but also about creating more awareness and, ultimately, improving eye care by identifying acquired color vision defects.

“We offer the Waggoner Computerized Color Vision Test as a standalone application/software, whereas, our competitors require hardware/software bundles,” said Mr. Waggoner. “Since we can distribute utilizing only software, we think we are doing a disservice to healthcare as a whole if we withhold the Waggoner CCVT. If the top five percent of eye care providers in a country have a hard time paying for the device, I think it’s a no-brainer to provide it to these countries and doctors complimentarily.”

And Mr. Waggoner’s efforts were clearly appreciated at APOC 2023, not only for the value he provided but also for the early disease detection that color vision testing can provide.

In fact, he shared that an executive board member from the Asia Pacific Council of Optometry took the test — and it revealed a mild tritan defect in one eye and a moderate tritan defect in the other, which was indicative of her previous macular degeneration diagnosis.

“It’s results like this that get doctors really excited about utilizing color in their practice,” shared Mr. Waggoner, who was also enthusiastic about APOC 2023. “I love going to shows where I’m immersed in the education aspect and get to learn about all of the science coming out of research institutes, while also seeing great technologies they are debuting or still working on. I was always learning something — and to me, that’s quite indicative of a successful conference.”

Dr. Subodh Dixit

Editor’s Note Dr. Cathy Stern

Dr. Rajeev Prasad

The 23rd Asia Pacific Optometric Congress (APOC 2023) was held from June 2 to 4 in Gurugram, India. Reporting for this story took place during the event.

Mr. T.J. Waggoner

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Conference Highlights |

SILMO 2023

SILMO Singapore 2023 New thoughts on myopia control, new trends in style

by Matt Young, COOKIE Magazine Publisher

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ears ago, an industry associate told me: “Matt, I think you might be in the wrong field.”

I was wearing something trademark funky at the time, and their ophthalmology booth and engagement with doctors were quite conservative. While I didn’t take it to heart, I always wondered: Would there be a larger place for me someday in our eye care space?

Fast forward to SILMO Singapore, and I was in my element. SILMO, which stands for “Salon International de la Lunetterie, de l’Optique Oculaire et du Matériel pour Opticiens” in French, is the premier eyewear show in the world, known for its annual flagship show in Paris.

Eyewear, of course, traverses the scientific and fashion realms. So there were the scientifically intellectual rigors of myopia control, which I do enjoy. But there was also the style side of the business — not exactly in outerwear like jackets — but definitely in frames. In fact, ahead of the show, I received two care packages of frames to check out. One was from my optometrist friend from Hanoi, Nguyen Huyen Trang, who has a line of frames called Martian. The other was from a family friend of Media Director Robert Anderson, Dr. Randy Rondowsky, who sent us a great mix

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of colorful, high-quality sunnies called Zbetr!

Suffice it to say, I may never have to pay full price for another set of frames in my lifetime, nor will my eyes ever have to suffer from a lack of style ever again.

My myopic puberty I’ve heard a lot of comments about myopia control over the last year, starting with the International Myopia Conference 2022 meeting in Rotterdam, all the way through the Asia-Pacific Myopia Management Symposium, also in Singapore.

Still, it has been hard to consider myopia as a critical disease, when all I had to do as a 13 year old in 1993 was to start wearing glasses, and perhaps identify a bit more with one of my favorite teenage movies: Revenge of the Nerds.

So when some new factoids hit me during SILMO Academy from a new friend, Prof. Mark Bullimore, Adjunct Professor at the University of Houston College of Optometry, I began to talk to my inner 13-year-old self about vision.

So, listen up, Young Matt. According to Mark:

COOKIE MAGAZINE | July 2023

• Higher myopes have worse vision even when fully corrected. That makes performing everyday tasks more complex. You don’t have high myopia now; if you do one day, you may be sorry.

• Myopic maculopathy is the greatest risk of higher levels of myopia. That’s something much more serious, and so take your myopia seriously, kid.

• Each diopter myopia increases the risk of POAG by 20%, the risk of PSC by 21%, and the risk of retinal detachment by 30%.

Believe it or not, my child, you will be writing about all this someday.

So, go ahead and look up those acronyms.

It’s probably fair I’m retrospectively talking to myself, because as Mark said, “We used to dread talking about [myopia]. We didn't have the therapies 20 years ago.”

So I may have been out of myopia control luck, but kids these days are in a way better position for treatment.

Phone a friend Right in the middle of SILMO Academy, I had to call Dr. Rajeev Prasad about his upcoming APCO regional optometry meeting in New Delhi in June. It was interesting to hear Rajeev’s take on myopia control, which was a bit of a devil’s advocate position.

“Not every child is a myopia management patient,” he said.

“There is overaggressive treatment.

The downside is nowadays, every ophthalmologist in India has started prescribing atropine.”

Long-term use of atropine does have side effects, he said. Of course, atropine is only one modality of myopia control.

Low-level red-light therapy is a new modality that many were intrigued by at SILMO Academy, as presented by ophthalmologist Prof. Mingguang He of China.

It is indeed a “promising alternative

treatment for myopia control in children with good user acceptability and no documented functional or structural damage,” according to his peer-reviewed paper in the journal Ophthalmology.

Meanwhile, Biten Kathrani, Head of R&D, Vision Care APAC at Johnson & Johnson, just had to stand nearby for me to remember that J&J just won the Ophthalmology Product Innovation accolade from Healthcare Asia Medtech Awards 2023.

The award featured the soft therapeutic lens innovation ACUVUE Abiliti 1-Day Soft Therapeutic Lenses (Johnson & Johnson, California, USA) for myopia management. With RingBoost technology, designed for

Here’s a sampling of some of the fashions our Creative Director Chris McBride and I were enjoying: 1. Matt and Chris: Finally, a place that values the intersection of fashion and eye care. Great to be covering SILMO with Chris McBride. Enjoying the heck out of this! Like our sunnies? They’re called The Jig & Sprinter from Zbetr. Check out https://zbetr. com/ website for cool frames.

children ages 7 to 12 years, the lenses have been shown to reduce axial elongation by 0.105 mm on average over six months.

Spectacles are also an important part of the myopia control equation.

So standing with May Zhang, Global Head of Professional Affairs, HOYA Vision Care, I was reminded of their MiYOSMART (HOYA Vision Care, Tokyo, Japan) spectacle lenses for kids. Important to note, as I do remember at least one speaker at SILMO Academy suggesting spectacles make more sense than atropine for kids.

opportunity to write about style, I led with science! Time to change that up.

But first, it’s important to note that this was SILMO’s first venture into Singapore. Eric Lenoir, Directeur du Salon for SILMO, expected a couple thousand delegates to show up. That did not seem to be the case in its first year, but there were more than 200 exhibiting companies, so definitely lots to see for anyone attending.

Editor’s Note SILMO Singapore 2023 was held from April 12 to 14 in Singapore.

Reporting for this story took place during the event.

Old habits die hard I can’t believe that given the

5. Our Creative Director Chris McBride apparently found his long-lost family member Michael McBride, shown here.

He’d typically say “no relation” but with Harry Potter frames at stake, Chris would like to say, “relation!” to get the family and friends discount.

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Admittedly, these fashions got Chris and I fired up to keep our SILMO style going at Marquee Nightclub into the wee hours of the night, where we saw some fellow SILMOers in an unofficial capacity. After all, it didn’t take an official gala dinner to make SILMO a happening place for happening people. What a breath of fresh eyec-air!

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2. Something about these Tide Optical frames makes Chris look like the human version of a cartoon character.

3. I really liked these orange KlassiC. Eyewear Frames; however, my face itself looked a little too orange.

4. I have to say, it wasn’t just the look, but the feel of the frames by LOOK that made me a believer. Alessandro Giacon, Export Manager of LOOK, explained that companies like his in northern Italy had a long history of eyewear manufacturing, contributing to the robust quality of frames.

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