COOKIE Issue 13: The Contact Lens Issue by Media MICE

THE CONTACT LENS ISSUE

October 2023

cookiemagazine.org

Letter to Readers

Beyond Vision Correction and patients. Not only that, smart contact lenses have been developed to monitor intraocular pressure (IOP) and even administer time-released medication for glaucoma treatment. Even the internet has joined in on the action! YouTube videos showing the ease of use and maintenance of contact lenses have contributed to the appeal of the devices. However, public education regarding the benefits of contact lens usage remains crucial for its broader adoption. Organizations such as the International Association of Contact Lens Educators (IACLE), the British Contact Lens Association (BCLA ), and the World Council of Optometry (WCO) continue to tirelessly reach out to vision care practitioners and educators, urging them to promote the versatility, safety, and affordability of contact lens use.

one are the days when contact lenses were only meant to correct vision. Today, they’re a seamless fusion of science and convenience—enhancing not just our sight but our lifestyles, too! Indeed, technology has ushered in a new era of userfriendly contact lenses. Advances and innovation in design and materials allow practitioners to prescribe contact lenses for a wider range of vision issues. Patients can now be fitted with scleral contact lenses to address problems such as keratoconus and dry eye. In orthokeratology, contact lenses have shown promising results in the management of myopia among children. Enhanced comfort and wearability have also contributed to improved regimen compliance, benefiting both practitioners

COOKIE MAGAZINE | October 2023

While the contact lens industry strives to innovate and bring to market contact lenses that are safe, user-friendly, easy to maintain, and affordable, it is important for vision care practitioners to keep abreast of new developments in this space. This way, we can prescribe and recommend new contact lenses that best align with our patient’s needs and financial considerations. Truly, in the ever-evolving landscape of eye care, contact lenses stand as a testament to our industry’s relentless commitment to innovation. As always, we hope you enjoy this issue of COOKIE magazine!

Best, Dr. Carmen Abesamis-Dichoso

OD, MAT, FPCO, FIACLE, FBCLA, FAAO

In This Issue...

Optics

Cool Optometry

Eye-Opening Contact Tidbits 10 fun facts about contact lenses to amaze and surprise your patients

Finding the Right Contact Lens Fit for Keratoconus

Malaysian optometrist Ms Oh Poh Ling shares her insights into the best contact lens options for keratoconus patients

An Eye-Catching Tale

From da Vinci’s visionary ideas to modern marvels, we revisit the evolution of contact lenses

Fix Contact Lens Complications – Doctor’s Orders! Dr. Jeffrey Walline shares his two cents on preventing contact lensrelated complications

Cover Story 14

Enlightenment

Kudos

The Lens Luminary

In the realm of specialty contact lenses and myopia control, Dr. Ashley Tucker fights vision loss one lens at a time

Innovation

From AR to Night Vision

What does the future of contact lenses look like?

The Battle Against Eye Care Waste

How to tackle the environmental issues posed by contact lenses—and the role optometrists and the eye care industry have to play in mitigating them A Look at Atropine

Three-year study reports atropine is less effective than placebo in myopia control

COOKIE MAGAZINE | October 2023

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

Matt Herman Associate Editor Maricel Salvador Graphic Designer

Dr. Kristie Nguyen

Dr. Feenstra and Associates; Dr. Kristie Nguyen PLLC, Florida, USA

Dr. Mark Eltis

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

Writers Andrew Sweeney April Ingram Ben Collins Joanna Lee Tan Sher Lynn

kristie817@gmail.com

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

Media MICE Pte. Ltd.

6001 Beach Road, #09-09 Golden Mile Tower, Singapore 199589 Tel: +65 8186 7677 Email: enquiry@mediamice.com www.mediaMICE.com

We are looking for eye doctors who can contribute articles to COOKIE magazine. Interested? Let's talk! Send us an email at editor@mediamice.com. To place an advertisement, advertorial, symposium highlight, video, email blast, or other promotion in COOKIE magazine contact sales@mediamice.com.

COOKIE MAGAZINE | October 2023

Cool Optometry |

Eye-Opening Contact Tidbits 10 fun facts about contact lenses to amaze and surprise your patients by Andrew Sweeney

Although contact lenses are a huge part of modern optometric practice, there's so much more to learn about these unassuming silicone wonders. We uncovered 10 amazing facts about contact lenses that you can use to impress your patients.

t’s impossible to imagine modern optometry or ophthalmology without contact lenses. While some patients would never choose to wear them due to various reasons, others have had their lives transformed by them. For this month’s edition of COOKIE magazine, we scoured the annals of history and dove deep into uncharted Internet territories to discover some amazing facts about contact lenses.

Rabbits were the first to wear contact lenses Most of you will know that contact lenses were first successfully manufactured by German ophthalmologist Adolf Gaston Eugen Fick in 1888, who fabricated the first afocal scleral contact lens. Made of brown glass, his first designs were heavy and naturally uncomfortable. But did you know who his very first patients were? As it turns out, it wasn’t humans. Instead, it was the lab rabbits that

LENS TRIVIA

Fick had at his disposal. Fick would eventually go on to try his lenses first on himself and then on volunteers. But isn’t the image of fluffy white rabbits in an 18th-century German laboratory wearing giant 18-21 mm brown lenses just so bizarre?

Contact lenses used to be categorized as drugs At one point, contact lenses were categorized as drugs by the United States Food and Drug Administration (FDA). This highlights how, at least initially, contact lenses had a lot of bureaucratic hurdles to jump through before wider adoption. This wasn’t even that long ago, historically speaking. It was only in 1971 when Bausch & Lomb (Quebec, Canada) released the first-ever commercial contact lenses in the US that the FDA finally reclassified them. This allowed the pharmaceutical company to start marketing soft lenses in the States, a move that would go on to revolutionize eye care.

low

Contact lens compliance is (un)surprisingly

As an optometrist, you know that getting patients to properly look after their ocular health can be difficult at the best of times, especially with contact lenses. How to wear them, when to take them out, how to clean them and maintain hygiene, among others—there's a lot for the average person to take in. But do you know how many of them fail to comply on a daily basis? Up to 25% of contact lens wearers completely fail to comply with their clinicians' usage recommendations.1

COOKIE MAGAZINE | October 2023

Cool Optometry |

LENS TRIVIA

in the US, which consisted mainly of colored or tinted lenses.4 This is projected to remain unchanged until 2024. While the vast majority of wearers don’t report any adverse effects, it’s worth mentioning to your patients that this may not be the best idea, as these lenses are not manufactured to the same exacting standards as the corrective variety.

You can fit 27 contact lenses into one eye It turns out that the ocular cavity has a considerable capacity for contact lenses. In another rare case from the UK (no, we don’t know why Britain has all of these bizarre contact lens cases either), a woman was found to have 27 contact lenses lodged in her eye.

What’s more, only 32% demonstrate satisfactory compliance overall. Perhaps it's time for optometrists to adopt stricter methods to ensure patient obedience.

There is gender disparity among contact lens wearers Women are from Venus, and men are from Mars… as the old saying goes. Although gender equality is closer than ever, there are still some key differences between the sexes. While this phenomenon is most associated with superficial issues, it turns out that there are noticeable differences in optometry, too. Case in point: According to the CDC,2 out of the estimated 45 million Americans who wear contact lenses, two-thirds of them are women. This disparity is particularly acute in the 18-24 age group, with an even 70/30 split. The difference is less noticeable among younger people aged 12 to 17, at 52/47.

Contact lenses can remain lodged in the eye for decades As an optometrist, you must’ve given hundreds, if not thousands,

of contact lens wearers the same warning during their visits: Take your contact lenses out before you go to sleep. Of course, as we've already mentioned, compliance can be a problem, and sometimes strange things happen as a result. In one case in the UK, an 81-year-old man had a lump around his eyelid, which turned out to be a contact lens that had remained lodged in his eye for 40 years since it was first inserted. According to the doctors involved in the case, this was the longest delay in diagnosis ever reported in the ophthalmic literature.3

Millions of people wear lenses solely for aesthetic reasons The vast majority of contact lens wearers wear contact lenses to correct visual problems. However, there is a considerable and growing market for those who want to wear lenses solely for aesthetic reasons. These lenses don't offer any vision correction whatsoever but instead, come in a range of colors and styles— from purple irises to contact lenses that turn the entire eye black. In 2016, the market share occupied by aesthetic contact lenses was 11%

COOKIE MAGAZINE | October 2023

Yes, you read that right, 27 contact lenses! And what was more remarkable was that she didn’t appear to have any visual problems. The 67-year-old was due to undergo routine cataract surgery, and somehow the ‘bluish mass’ of the contact lenses had eluded both herself and her optometrists up until that point. The lenses were removed safely to no ill effect.

NASA developed contact lenses for outer space Now, this is something that's really 'out of this world’! NASA actually helped to develop contact lenses that could be used by its astronauts in outer space. In 1993, the agency collaborated with Paragon (Arizona, USA) to create a contact lens that could work in an environment where gravity is significantly reduced, as interactions between solids and liquid are worlds different than on the Earth’s surface. Paragon subsequently developed its hyper-purified delivery system contact lenses based on its cooperation with NASA. They were designed to be gas-permeable and didn't contain any water whatsoever, making them significantly less likely to harbor harmful bacteria. These lenses could also be worn for up to seven days at a time.

Contact lenses cure angsty teens Do you remember when you were a socially awkward, gangly teen? Being a teenager is tough under the best of circumstances, but especially so when you have a vision problem. The good news is that contact lenses can help with that. Studies5 have consistently shown that children who wear contact lenses instead of conventional glasses report significantly higher confidence, better sporting performance, improved self-image, and even enhanced school performance. Indeed, it seems contact lenses are a win-win when it comes to boosting the happiness of angsty teens.

The best (of lenses) is yet to come The coolest fact we can tell you about contact lenses is that there is so much to look forward to in the coming years! Lenses are at the forefront of technological development in both ophthalmology and optometry, using some of the most avant-garde technologies available, including artificial intelligence, 3D printing, drug-eluting and more! Of course, COOKIE magazine is following many of these latest updates in this very issue. No one knows what other contact lens oddities the future could bring—but we are certain they will be cool.

References 1. Bui TH, Cavanagh HD, Robertson DM. Patient Compliance During Contact Lens Wear: Perceptions, Awareness, and Behavior. Eye Contact Lens. 2010;36(6):334-339. 2. Healthy Contact Lens Wear and Care. Available at https://www.cdc.gov/ contactlenses/fast-facts.html. Accessed on August 2, 2023. 3. Shams PN, Beckingsale AB, Sheldrick JH, Rose GE. An unusual eyelid lump: unsuspected embedded contact lens for up to 40 years. Two cases and literature review. Eye (Lond). 2011;25(10):1371-1373. 4. Contact lenses in the US - Statistics & Facts. Available at https://www.statista. com/topics/4570/contact-lenses-in-the-us/. Accessed on August 2, 2023. 5. Building children’s confidence with contact lenses. Available at https://www.visiondirect. co.uk/blog/building-childrens-confidencecontact-lenses. Accessed on August 2, 2023.

Industry Update

GOMCC 2023 Shaping the future of vision care The 4th Global Orthokeratology & Myopia Control Conference (GOMCC 2023) brought together global experts in orthokeratology and myopia control, focusing on cutting-edge technologies and practical solutions.

Editor’s Note

The 4th Global Orthokeratology & Myopia Control Conference (GOMCC 2023) was held from September 26 to 28, 2023. Reporting for this story took place during the event.

rom September 26 to 28, GOMCC 2023 took place at the Singapore Polytechnic Convention Centre. The conference served as a gathering point for ophthalmologists, optometrists, researchers, and industry leaders from across the globe to discuss the latest developments, research, and clinical advances in orthokeratology and myopia control. Innovative treatment strategies for myopia control were a paramount theme during the conference. Experts delved into the latest advancements and technologies, such as the development of an artificial-based ortho-k lens fitting platform, the SEED "Breath-O Correct” orthokeratology contact lens, which offers oxygen permeability (DK) of up to 156, as well as the Essilor® Stellest™ lenses with the HALT technology to slow down myopia progression in children. New evidence and advances in myopia management were also explored, including the role of outdoor time,

combination treatment, use of contact lenses in childhood, extended depth of focus contact lenses for myopia control, and precision biometry measurement. The conference was not merely a platform for theoretical discourse, it also showcased real-world implementations and clinical case studies. Renowned practitioners shared their success stories, highlighting the transformative impact of orthokeratology in curbing the progression of myopia, especially in children. These real-life accounts served as inspirational narratives, motivating others to embrace innovative techniques in their practices. With a focus on practicality and realworld applications, GOMCC 2023 has paved the way for a more informed and proactive approach to myopia control, ensuring that the knowledge shared at the conference translates into meaningful improvements in vision care worldwide.

Brandon Winkeler (Media MICE) with Pak Seong Woon (Advisor to the Association of Malaysian Optometrists) at the recently held GOMCC event in Singapore

COOKIE MAGAZINE | October 2023

Cool Optometry |

COMPLICATIONS

Fix Contact Lens Complications – Doctor’s Orders! Dr. Jeffrey Walline shares his two cents on preventing contact lensrelated complications by Andrew Sweeney

Contact lenses are gaining more popularity than ever, with millions of people around the world adopting them for daily use. However, just like any medical procedure, they come with complications. We spoke with Dr. Jeffrey Walline, a prominent optometrist at the Ohio State University College of Optometry, to discuss the risks of eye infections and trauma when using contact lenses, as well as measures to prevent them from happening.

rom a scientific point of view, contact lenses have a relatively short history. But ever since the modern iteration’s widespread introduction to the ocular health industry in the 1970s, their popularity has only continued to grow.

Despite their immense popularity, however, contact lenses are still not used correctly by many patients, leading to an increased risk of numerous health issues, ranging from minor to eyesight-threatening complications. Some of the most well-known complications include various corneal problems, such as epithelial edema, micro-cysts, abrasions, conjunctival issues like allergic conjunctivitis, giant papillary conjunctivitis, and superior limbic keratoconjunctivitis.1,2

Nip infection in the bud Dr. Jeffrey Walline, associate dean of research and a professor at the Ohio State University College of Optometry, has decades of experience working in optometry. He has treated patients affected by contact lens complications, both common and rare. According to Dr. Walline, contact lens complications are an important issue that should be more widely recognized, especially since most cases are entirely avoidable.

Today, there is a plethora of contact lens options available on the market for different purposes. There are lenses designed for purely aesthetic reasons and some that can permanently correct vision without laser intervention. And in the near future, lenses that facilitate drug delivery are next in line to take off.

“Most contact lens complications are very minor and include dry eye and eye redness. However, some complications can be devastating to the patient. Poor compliance with contact lens care can lead to an eye infection, causing severe pain and potentially permanent vision loss,” Dr. Walline said.

There are up to 140 million users of contact lenses worldwide, a number that continues to increase.1 Optometrists encounter many contact lens wearers on a daily basis, and no doubt must deal with some of the complications that can occasionally arise from contact lens usage.

“Generally, people can avoid severe complications by following the doctor’s advice and calling the doctor if the eye becomes painful or red, or if they experience unclear vision. Even the most severe problems can be alleviated with quick treatment,” he continued.

While contact lenses are

generally safe to use, there will always be a risk of complications and other negative side effects. Fortunately, most of these complications can be easily avoided with patient compliance.

COOKIE MAGAZINE | October 2023

Beyond mere eye infections Eye infections in particular concern

“If the cornea becomes scarred, then it can lead to blurry vision—even while wearing glasses or contact lenses. Most of these complications can be avoided by not allowing tap water to touch the contact lenses, by avoiding sleep while wearing contact lenses, and by immediately contacting the eye doctor. If a patient’s eyes are red, painful, or can’t see, they should remove their contact lenses,” he said.

The pros of disposables Dr. Walline’s instructions above for preventing complications related to contact lens usage might seem clear and straightforward.

Dr. Walline, as they can cause some of the most serious problems for patients, including vision loss. One of the most severe of these infections is superior limbic keratoconjunctivitis, a hypersensitivity reaction to thimerosal or other preservatives in contact lens solutions, which usually present bilaterally and asymmetrically. Some of the most common symptoms that align with those listed by Dr. Walline above include pain, redness, and foreign body sensation.3 Then there's the more common complication, allergic conjunctivitis, which has been reported with thimerosal-containing lens solutions. Patients experience pain, redness, itching, and burning sensations in a reaction that usually develops days to months following exposure to thimerosal. Upon examination, clinicians usually find conjunctival hyperemia and the papillary response of the conjunctiva. Steroid eye drops should be used in tapering doses to prevent this reaction.4 “Eye infections can lead to extreme pain and may lead to permanent vision loss. While the pain is temporary, the front of the eye is the most sensitive place on the entire body, so the pain associated with an eye infection is extremely debilitating. The infection can lead to scarring of the cornea, the clear window on the front of the eye,” Dr. Walline explained.

But let’s face it, there’s always that one patient who’ll never listen no matter how much one may try. In cases like this, ODs can recommend the option of switching to daily disposable contact lenses instead, as these have been associated with a reduced number of complications. “Daily disposable contact lenses have been shown to result in the fewest complications. Although they may be more expensive than contact lenses that are thrown away every two or four weeks, when you consider the cost of solutions and cases for these lenses, the difference in cost is typically worth the added convenience, comfort, and health benefits,” Dr. Walline said. Dr. Walline's preference for daily disposable lenses is supported by scientific research. Abrasions caused by trauma or mechanical injury due to the lens, insertion, or removal of the lens can result in corneal scarring, which also increases the risk of infection. Superficial punctate keratitis can also occur due to mechanical injury from the lens or during lens application. So can fungal keratitis and several other conditions associated with long-term wear of contact lenses.

Discarding lenses before bedtime There's one more piece of advice from Dr. Walline, albeit a very

important one: Don't sleep with your contact lenses on! This is likely the single most dangerous practice that leads to complications, and one that can be easily avoided. Optometrists must thus make sure to consistently emphasize this to their patients. "Patients must be continually reminded to avoid sleeping with their contact lenses on, as this may not only result in discomfort but also increase the risk of an eye infection tenfold. Patients should also schedule routine eye care appointments to proactively address any issues, rather than waiting until they start affecting vision or comfort," concluded Dr. Walline.

References 1. Gurnani B, Kaur K. Contact Lens-Related Problems and Complications. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 2. Wan SJ, Kroken AR, Nieto V, et al. Contact lens-related corneal infection: Intrinsic resistance and its compromise. Prog Retin Eye Res. 2020;76:100804. [Epub 2019 Nov 20] 3. Bradley CS, Sicks LA, Pucker AD. Common Ophthalmic Preservatives in Soft Contact Lens Care Products: Benefits, Complications, and a Comparison to Non-Preserved Solutions. Clin Optom (Auckl). 2021;13:271-285. 4. Singh RB, Liu L, Anchouche S, et al. Ocular redness - I: Etiology, pathogenesis, and assessment of conjunctival hyperemia. Ocul Surf. 2021;21:134-144. [Epub 2021 May 16]

Contributing Doctor Dr. Jeffrey Walline, OD, PhD, is a professor and associate dean of research at the Ohio State University College of Optometry. He received his Ph.D. in vision science at the same institute and studied for his bachelor's in optometry at the University of California, Berkeley. Dr. Walline specializes in treating several conditions, including myopia, keratoconus, and corneal trauma, and is highly regarded for his expert knowledge of contact lenses and their associated risk factors. walline.1@osu.edu

COOKIE MAGAZINE | October 2023

Optics | SCLERAL LENSES

days, it is now possible to fit nearly all types and shapes of corneas,” she continued. Ms. Oh dove into the following contact lens options currently available for keratoconus patients:

Scleral lenses These are large-diameter lenses that vault over the entire cornea and rest on the sclera. These lenses create a space between the lens and the cornea, which is filled with saline solution or, in some cases, eye drops.

Finding the Right Contact Lens Fit for Keratoconus Malaysian optometrist Ms. Oh Poh Ling shares her insights into the best contact lens options for keratoconus patients by Tan Sher Lynn

COOKIE magazine recently caught up with Ms. Oh Poh Ling, who specializes in contact lens fitting for keratoconusaffected eyes. She discussed a range of specialty contact lenses designed for irregular or diseased corneas, as well as the fitting process for these lenses.

ith keratoconus, characterized by irregular corneal shape, vision can become distorted, and regular eyeglasses may not provide sufficient correction. Moreover, the process of fitting contact lenses for keratoconus patients can be more challenging compared to fitting lenses for individuals with normal eyes. “The irregular corneal shape requires

specialized lenses that conform to the cornea’s contour, providing better vision and comfort,” shared Ms. Oh. Fortunately, nowadays, there are specially designed rigid corneal lenses, as well as customized soft lenses, which can be used to provide these patients with optimum visual outcomes. “With software-based designing and high customization options available with lenses these

COOKIE MAGAZINE | October 2023

“Semi-scleral lenses are typically employed for patients with irregular corneas, such as those experiencing keratoconus. However, they can also be beneficial for individuals with normal corneas who are grappling with dry eye symptoms and find it challenging to wear standard soft or semi-hard lenses. The fluid-filled space between the cornea and the lens created by sclera lenses provides comfort and improved vision for those with irregular corneas,” explained Ms. Oh.

Rigid gas permeable (RGP) lenses RGP lenses are smaller than scleral lenses and offer excellent visual correction for irregular corneas by maintaining a smooth optical surface over the damaged or irregular cornea. “These lenses are commonly recommended for individuals dealing with mild to moderate keratoconus. Within this classification, they are further categorized into four distinct types: ROSE K2, ROSE K2 nipple cone, ROSE K2 irregular cornea, and ROSE K2 post graft. The specific lens chosen depends on the unique irregularities present in the cornea’s shape. By tailoring the lens selection to match the cornea’s contours, improved comfort and vision are achieved, as the lens can achieve an optimal fit on the cornea,” she summarized.

Hybrid lenses Hybrid lenses have a rigid center with a soft outer skirt. The rigid center

corrects the irregular cornea's shape, while the soft skirt enhances comfort and lens stability. “Hybrid lenses serve not only patients with keratoconus but also those grappling with high astigmatism and presbyopia, especially when conventional soft or customized lenses prove inadequate in terms of adaptation and comfort. In cases of keratoconus, these lenses offer a dual advantage—clear vision through their rigid center and sustained comfort via the presence of a soft outer ring,” she said.

corneas. By combining the usage of a soft contact lens atop an RGP lens, this approach offers enhanced “Hybrid lenses serve comfort and not only patients with improved clarity keratoconus but also of vision for the those grappling with patient,” she remarked. high astigmatism and

presbyopia, especially when conventional soft or customized lenses prove inadequate in terms of adaptation and comfort. In cases of keratoconus, these lenses offer a dual advantage—clear vision through their rigid center and sustained comfort via the presence of a soft outer ring.”

Custom soft lenses These are specially designed soft lenses made to match the unique contours of the cornea, providing comfort and visual correction for certain cases of corneal damage. "Tailored soft lenses are designed for individuals with irregular corneas, post-surgical corneal situations, high prescriptions, and presbyopia. They offer versatility across various conditions and prove especially advantageous for addressing irregular corneas or scenarios where standard soft lenses fall short in delivering optimal visual outcomes,” Ms. Oh further explained.

Piggyback lenses These involve wearing a soft lens underneath a rigid gas-permeable lens to enhance comfort, while still providing visual correction for irregular corneas. “Finally, piggyback lenses cater to individuals with mild to moderate keratoconus as well as irregular

From fitting to follow up

According to Ms. Oh, in the optometrist center where she works, she has encountered numerous patients with complex corneas. Below, she outlined her treatment process—from the initial evaluation and fitting to subsequent follow-ups. “The process begins with a comprehensive eye examination and corneal evaluation. Specialized diagnostic tests like corneal topography, keratometry, and corneal pachymetry are used to assess the shape, curvature, and thickness of the cornea. This helps in understanding the extent of corneal irregularities or damage,” Ms. Oh began. “Based on the evaluation results, we will then determine the appropriate type of contact lens for the patient's specific condition. Factors like the severity of corneal irregularities, tear film stability, and patient lifestyle are considered when prescribing the lenses,” she continued. The fitting process involves selecting the size and parameters of the contact lenses to ensure they fit comfortably and securely on the eye. For semi-scleral lenses and custom soft lenses, precise measurements of the cornea are obtained to create lenses that are specifically tailored to the individual's needs.

Ms. Oh shared a case of a keratoconus patient who had been using ROSEK2 lenses (RGP lenses) for an extended period. “Due to the progression of his keratoconus, he has developed an intolerance to these semi-rigid lenses. As a result, we had to transition to semi-scleral lenses, which are particularly suitable for more advanced keratoconus cases. The large diameter of the lens ensures that it rests on the sclera, avoiding contact with the sensitive and irregular corneal surface, thus providing better comfort and improved vision,” she said. After the delivery of the lenses, Ms. Oh would schedule regular follow-up visits with her patients to monitor the progress and make any necessary adjustments to the lenses, if any. This helps ensure the contact lenses are providing optimal vision correction and comfort. Ms. Oh also noted that patients with severe corneal diseases or irregularities may require multiple fittings or a combination of different lenses to achieve the best results. In such cases, close collaboration between the optometrist and the patient is essential to address any challenges that may arise.

Contributing Doctor Ms. Oh Poh Ling is a dedicated optometrist who completed her studies at SEGi University, Malaysia, in 2017. With over six years of valuable experience as a practicing optometrist at Vision Space Optometrist, she dedicates herself to providing patients with comfortable vision. Her primary focus includes helping children effectively manage short-sightedness through myopia control treatment. Additionally, Ms. Oh’s strong passion lies in aiding those with keratoconus to achieve improved visual acuity. pohling@visionspace.com.my

COOKIE MAGAZINE | October 2023

Optics | CONTACT LENS HISTORY

An Eye-Catching Tale From da Vinci’s visionary ideas to modern marvels, we revisit the evolution of contact lenses

by Ben Collins

From blown glass creations of days past to modern spacefaring contact lens experiments, we've come a long way. With smart lenses, microelectronics and drug delivery breakthroughs, the evolution of these little eye wonders presents a spectacular tale!

hile Leonardo Da Vinci can be credited with initially conceptualizing the contact lens,1 it was German ophthalmologist Adolf Gaston Eugen Fick who successfully fabricated (and fitted) the first afocal scleral contact lens in 1888.2 Made from blown glass, they were large, cumbersome, and could only be worn for a few hours. However, technological and material

advancements meant that by the late 1930s, lenses were being made entirely out of plastic, becoming essentially the early versions of the product we know today.

This was an uncomfortable process, as early scleral lenses often shifted out of alignment—or popped out altogether—as well as deprived the eye of oxygen.

A patchy start

Thankfully, the development and use of the keratometer eliminated the need for eyeball impressions. Reductions in lens diameter have also led to a more ergonomic product.

To fit and manufacture these rudimentary contact lenses, a mold was first created using an impression of the patient's eyeball, and the lens was formed from this.

COOKIE MAGAZINE | October 2023

These days, lens manufacturers are

constantly developing and advancing their products with different materials and technologies. However, the primary material used to produce contact lenses is still a plastic polymer—PMMA for hard lenses and PHEMA for soft contact lenses.

The modern-day process There are two main ways in which modern-day contact lenses are manufactured: By cutting a blank on a lathe or injection molding. Lathe cutting involves spinning the blank (also known as a ‘button’, a circular disk of lens material slightly larger than the desired finished product) on a digital lathe. Rotating at over 6000 rpm, a diamond or laser cutting tool shapes the curvature and thickness of the lens according to the patient's specifications. The lens is then buffed and polished to eliminate any imperfections, and a technician shapes the edge. Finished lenses are thoroughly tested and sterilized before packaging. While the shaping process only takes around 15 minutes, an additional hydration stage (impregnating the lenses with liquid, making them soft and gel-like) can take another 24 hours. The whole procedure is computerized, ensuring quality and efficiency. This method of production can easily produce over 1,000 lenses per day. Molding was originally done using the spin-casting technique. Three different liquids are poured into the mold and the centrifugal force

of the spinning mold causes the polymerization of these fluids to form hydrophilic plastic. The outside curve of the lens is shaped by the mold, and the inside curvature is formed from the speed of rotation on the mold. Injection molding involves injecting molten plastic into the mold under pressure. The lens is then removed from the mold and cooled before finishing on a lathe. Some modern computerized techniques allow for the lens to be finished entirely through the injection molding process. From ortho-k to toric lenses, there’s a lens for everything these days. Bifocal, diffractive, monofocal, multifocal, and simultaneous vision lenses can also be fitted to treat presbyopia.3

The future looks clear Continuous research and experimentation are underway to explore different materials and polymers. Siloxane, which allows 25 times more oxygen permeability compared to current standard lenses, promises game-changing implications—particularly for extended-wear contacts and scleral lenses. There are even experiments with materials in outer space! Trials aboard the space shuttle Endeavour suggest the zero-gravity environment could lead to more oxygen-permeable and debris-resistant contact lenses.4 Triggerfish from Sensimed (Etagnières, Switzerland) is

another example of the continuous technological innovation occurring within the contact lens space. Triggerfish is a soft lens made from hydrophilic hydrogel fitted with onboard microelectronics, which can monitor patient intraocular pressure (IOP) in real time. The lens can be worn for 24 hours, and recorded information is transmitted to a computer via Bluetooth. With particular implications for glaucoma management, this device can help measure the effects of various factors such as medication, sleep patterns, and body position on IOP.5 Ocular drug delivery is another area in which contact lens innovation is showing promise. MediPrint Ophthalmics (California, USA) has developed a noninvasive drug delivery system using contact lenses. While still in its early phase, the system could have positive implications for the management of myopia, dry eye, allergy, and glaucoma, as well as post-cataract surgery treatments.6 So, from Da Vinci's visionary experiments to zero-gravity manufacturing processes, along with sci-fi-inspired ocular drug delivery systems, the evolution of the trusty contact lens looks anything but blurry!

References 1. Heitz RF, Enoch JM. Leonardo da Vinci: An assessment on his discourses on image formation in the eye. Advances in Diagnostic Visual Optics. 19-26, Springer-Verlag. 2. Adolf Eugen Fick (1852-1937). Available at http://www.sciencemuseum.org.uk/ broughttolife/people/adolfeugenfick.aspx. Accessed on August 3, 2023. 3. Gurnani B, Kaur K. Contact Lenses for Presbyopia. Stat Pearls [Internet]. 2023 May 4. 4. Contact Lenses. Available at http://www. madehow.com/Volume-2/Contact-Lens.html. Accessed on August 3, 2023. 5. Dunbar GE, Shen BY, Aref AA. The Sensimed Triggerfish contact lens sensor: efficacy, safety, and patient perspectives. Clin Ophthalmol. 2017;11:875-882 6. MediPrint’s drug-releasing contact lens reduces intraocular pressure in glaucoma patients. Available at https://www.medicaldevicenetwork.com/news/mediprints-drug-releasingcontact-lens-reduces-intraocular-pressure-inglaucoma-patients/. Accessed on August 3, 2023.

COOKIE MAGAZINE | October 2023

Cover Story

by Matt Herman

The contact lens business is booming, and in the process smashing pundit predictions to pieces. Massive growth is forecasted ahead, and the phenomena fueling it are multifaceted. From the contact lens’ uncanny ability to adapt to the seemingly infinite possibilities in optical designs afforded by modern manufacturing, these little wonders aren’t going anywhere any time soon. We sat down with Dr. Nadia Afkhami of Vision Care Partners to take a look at the staying—and growing—power of the humble contact lens.

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echnology is, by nature, ephemeral. The feverish pace of human innovation makes sure of that. Grandparents tell their progeny in shaky voices and hushed tones of the marvels of ages past. The graveyard of obsolescence grows by the day. So when an invention sticks around for a while, something special must be afoot. The contact lens has been around for a while. We’ve charted the history of the contact lens elsewhere in this issue (insert page number later), but just for fun: The first mass-market disposable dailies were introduced in the mid-nineties. Since then the cassette, the CD and the standalone MP3 player have all been (mostly) consigned to the catacombs of music history. At the turn of the millennium, most Americans were reading about the adoption of silicone hydrogel—the material used in the vast majority of modern contacts today—using dialup internet. They would have then scheduled their fitting appointment using a hardwired home phone— unless someone was using the internet, of course. Or, if they were among the lucky ones, a fancy flip cell phone could have gotten the job done. So long has it been since the modern form of the contact lens emerged. And odds are, even more seemingly bulletproof technologies will be discarded into the garbage heap of history before the contact lens.

A deepening patient pool The point is that contacts, in their current and most popular form, have weathered the sands of time well. More than well, actually. The contact lens market is thriving. A recent report from Fortune Business Insights1 has forecasted growth from an estimated USD 10.35 billion in 2023 to an eye-watering 15.4 billion by 2030, an astounding compound annual growth rate (CAGR) of 5.8%. For reference, the human population is expected to grow from 7.89 billion today to 8.5 billion2 by 2030—a comparatively paltry annual growth rate of 1.07%.

All despite the fact that the doom of the contact lens has been foretold by pundits and laymen since its invention. Contacts have been offhandedly dismissed throughout the years as too hard to put in, too annoying to care for, too uncomfortable, unsanitary, and too expensive. The list of would-be contact conquistadors is long, too: Laser vision correction (LVC), implantables like implantable collamer lenses (ICLs) and other phakic IOLs, as well as low-cost spectacles. All have been touted as the downfall of the contact lens, and yet—here we are. So, what gives? Well, for starters, the ongoing myopia epidemic means that the total pool of patients needing refractive correction is increasing. When 50% of the world is projected to be myopic by 2050,3 many of them will opt for contacts. Dr. Nadia Afkhami, an optometrist at Vision Source Oviedo, has seen this firsthand in her busy clinical practice. “We’re doing so much near work lately as a society. People are a lot more nearsighted now, and myopia is growing,” she observed, echoing the consensus on the post-pandemic world. But the raw increase in numbers cannot explain everything. In this ever-deepening pool, many people will opt for contact lens competitors like ICLs, glasses and laser. Innovation in the device itself has a role to play in driving the industry’s growth. And with myopia, it’s all about the (sort of) new kid on the block: Myopia control contact lenses.

Myopia control: Cleared for takeoff As it stands right now, the road to taming the axial elongation that causes myopia runs through contacts. Soft dailies that slow or halt the disease have arrived relatively recently. But they are poised for big things. CooperVision’s MiSight® 1 day (California, USA) and Johnson & Johnson’s ACUVUE® Abiliti™ 1-Day

(Florida, USA) lenses carry all of the pluses of contact lenses, with the added benefit of stopping axial length elongation in its tracks. Orthokeratology is also fully onboard this myopia-fueled rocket to the moon. Though ortho-k has been around for a while, it is experiencing a raucous renaissance as of late. Another report by Fortune Business Insights4 has the ortho-k market growing from $763.9 million in 2022 to $2,043.6 million by 2029—a blazing fast CAGR of 15.1%. Dr. Afkhami sees the simplicity of ortho-k as being one factor behind this astronomical projected growth. “It’s easier, I think, to push [corneal refractive therapy] or ortho-k, because you put them on, you wake up in the morning, and you have perfect vision for the day,” she related. Of course, it also pays to be the only act in town. Contact lenses are currently the only FDA-approved treatment modality for myopia control. Atropine must still be used off-label, and the drug’s push to join the club has been hamstrung by poor performance in a recent study.5 Myopia control spectacle lenses have similarly stumbled out of the starting gate. Despite Essilor’s Stellest™ lenses (Charenton-le-Pont, France) receiving a “Breakthrough Device” designation by the FDA in mid-2021, full approval has proven to be elusive. The same goes for Hoya’s MiYOSMART (Tokyo, Japan) offering and the countless others waiting in the wings. “It’s all about patient preference, and everyone’s a little bit different,” Dr. Afkhami commented on the myopia control landscape.“I think that it’s nice that we have some treatment options available for myopia,” she concluded. And the fact that the FDA-approved options are all contact lenses just means adding more fuel to the on-fire contact lens market.

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Cover Story

Contact cornucopia Myopia control options are just the tip of the iceberg in terms of what the modern contact lens can do. Though the basic form and materials used to manufacture contact lenses haven’t changed since the days of Napster and AOL Instant Messenger, advances in manufacturing processes and clever optical designs have yielded other wonders. One of these is disposable multifocal contact lenses. The world’s population is getting older,6 and with age comes the inevitability of presbyopia. Enter multifocals, whose share of the contact lens market is projected to grow1 as the world collectively succumbs to Father Time at higher rates. “It’s kind of hard to wear contacts and then have to throw on the readers, right? The point of contact lenses is not having to wear glasses in the first place,” Dr. Afkhami commented on the rise of multifocal contact lenses. “Now with current technology, I think with everyone coming to that age, we try to give them a shot with multifocals,” she continued. “We may have to tweak it a few times, but in the long run I think they’re willing to compromise a little bit so that they don’t have to carry around reading glasses,” she concluded. And, of course, a little bit of old-fashioned denial goes a long way. “Maybe they also don’t want to feel old by needing the little extra help from reading glasses,” she added. Astigmatism is another area where the modern contact lens has entered fertile ground. Traditionally the preserve of glasses, patients with cylinder now have spectacle-free options—thanks to the ingenuity of modern optical design. Extendedwear soft torics are another massive driver of contact lens growth,1 and as flaws like rotational instability are overcome, toric versions of the market’s most popular lenses are finding their way more and more into mass use.

Myopia, presbyopia and astigmatism aren’t the only diseases that contacts can help overcome, either. Scleral contact lenses (though purists might argue they are not true ‘contact’ lenses because they don’t touch the cornea) are also a force to be reckoned with in the staying power of the modern contact lens. The use cases for scleral lenses are expansive and growing more numerous by the day. Patients with nearly any corneal disease, dystrophy, defect or irregularity can be corrected with scleral lenses nowadays. And if, heaven forbid, a patient’s laser vision correction needs a tuneup, scleral lenses have their back. Dr. Afkhami especially likes sclerals for patients at the more extreme end of the astigmatism spectrum, further cementing their role in the contact lens pantheon. “I try to put higher cylinder patients into a scleral lens because sometimes the comfort’s not there with a soft contact lens,” she said. And when patients with both high and low astigmatism are added to the wide range of patients who can be fitted comfortably with contacts, the mystery behind the projected growth of the contact lens market lessens even more.

Spectacular sans spectacles Speaking of comfort, one large stone in the contact lens growth landscape remains unturned. Yes, contact lenses have expanded their use cases to include the vast majority of the planet’s eyes. But the original appeal of contacts, and arguably the reason for which they were invented, is perhaps the greatest contributor to the device’s longevity: Lifestyle and aesthetics. The need for spectacle independence has and will always be a driving force in eye care. From IOLs to LVC to, yes, contact lenses, freedom from glasses will always be big business. There are many professions that require or

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advantage glasses-free employees, but the kind of growth forecasted must ultimately find its sources in new users. Dr. Afkhami sees a lot of growth coming from the self-confidence market, especially among younger demographics. “I think teenagers are more prone to ask about contacts because this is a time for confidence and this is a time for growing into yourself. And sometimes they think that glasses can hold them back,” she said. This attachment to contact lenses and wanting to be spectacle-free are not new. “We had those old Acuvue commercials where the twins would wear them—one had glasses, one was in contacts, and the point was that the one in contacts looked so much better. These kinds of marketing techniques have always been passed down, and especially over the last couple of years with social media,” she noted.

Lonely at the top? Contact lenses are obviously not the only way to correct vision without glasses. But competitors in the spectacle-free realm have their own issues, ensuring there will always be a space for contacts. Deserved or not, laser vision correction has always had a stigma of danger attached to it. This has only worsened as of late with the FDA’s controversial draft guidance for LVC. The Jonas Brothers’ recent plug of ICLs aside, the fear of going under the knife and life-altering complications will always limit the appeal of surgical alternatives for those looking to correct refractive error. On top of this, both procedures are considered to be cosmetic in the United States and elsewhere, placing them firmly outside the realm of insurance coverage and, thus, affordability for many. Dr. Afkhami sees the eye’s natural changes as it ages as another factor constraining the mass adoption of

surgically-based refractive correction as well. “If someone is in their 30s and they’re asking me about LASIK, I say ‘Hey, listen—realistically, in 10 years you’re going to need reading glasses. Is this worth the time and money when you’re just gonna throw glasses on again?’” she related. “The answer is usually no.” Speaking of spectacles, logic would dictate that their rising popularity would be a prime candidate for pulling the air out of the contact lens party. Dr. Afkhami believes that glasses are timeless and aren’t going anywhere. “I do think that the numbers with glasses have gone up in the last few years—they’re trendier, they’re more stylish,” she admitted. “In the eye care industry, we’ve been pushing [glasses]. It’s part of your style—it’s an accessory now,” she concluded. The important thing to notice here, however, is that the contacts vs. glasses battle is not a zero-sum game. “Most contact wearers I see, they wear both,” she said. “Like a lot of my patients, I just supplement one with the other.” Glasses these days are also significantly faster, cheaper and easier to obtain than ever before, but this could actually be a hidden boon to contacts in some markets. As Dr. Afkhami explained, insurance in the United States only covers one form of vision correction. Because contacts are significantly more expensive, patients are inclined to charge this more expensive option to their insurance when a cheap and effective pair of glasses can be had for a few bucks in a matter of days.

Here for the long haul Ultimately, there are many reasons why contact lenses are taking on a more significant role in refractive error correction. Their detractors, however, are not wholly wrong about the issues with contact lenses. Dry eye rates are rising. Contact

wearers are more prone to infection. Compliance is low. And specialty contacts like those for myopia control can only be used by a restricted group of patients who need them. But in the end, the contact lens will never go out of style for one reason: Ultimate flexibility. As reports from experts like Dr. Afkhami and industry insiders have noted, this wonder device’s ability to adapt to society’s changing needs is its ultimate insurance against what the future will bring.

Contributing Doctor

References 1. Contact Lenses Market Size, Share & COVID-19 Impact Analysis, By Modality (Reusable and Disposable), By Design (Toric, Multifocal, and Spherical), By Distribution Channel (Ophthalmologists, Retail Stores, and Online Stores, and Regional Forecast, 2023-2030. Available at https://www.fortunebusinessinsights. com/industry-reports/contact-lensesmarket-101775. Accessed on September 4, 2023. 2. Population. Available at https://www. un.org/en/global-issues/population#. Accessed on September 4, 2023. 3. 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. 4. Orthokeratology Lens Market Size, Share & COVID-19 Impact Analysis, By Type (Overnight Lens and Daytime Lens), By Age Group (Children and Adults), By Application (Myopia, Astigmatism, and Others), By End-user (Optometrist Offices, Hospitals & Ophthalmology Clinics, and Others), and Regional Forecast, 2022-2029. Available at https://www.fortunebusinessinsights. com/orthokeratology-lens-market-103110. Accessed on September 4, 2023.

Dr. Nadia Afkhami graduated from the Western University of Health Sciences College of Optometry in Pomona, California. She grew up in Central Florida, earned her Undergraduate Degree at the University of Central Florida, Orlando Campus, and later pursued her Master’s Degree at Barry University in Miami, Florida. In 2022, she received the Eyecare Business Magazine Game Changer Award. Dr. Afkhami started her social media journey as a student and has continued to grow her online presence through her Instagram, EyeAmDrNadia, allowing her to work with many industry professionals over the years. In her spare time, she is passionate about community outreach for young women and children who have an interest in science, and she enjoys spending quality time with friends and family. nadiaafkhami@gmail.com

5. Repka MX, Weise KK, Chandler DL, et al. Pediatric Eye Disease Investigator Group. Low-Dose 0.01% Atropine Eye Drops vs Placebo for Myopia Control: A Randomized Clinical Trial. JAMA Ophthalmol. 2023;141(8):756-765. 6. Ageing. Available at https://www.un.org/ en/global-issues/ageing. Accessed on September 4, 2023.

COOKIE MAGAZINE | October 2023

Kudos |

WOMEN IN OPTOMETRY

In the realm of specialty contact lenses and myopia control, Dr. Ashley Tucker fights vision loss one lens at a time by Chow Ee-Tan Dr. Ashley Tucker, director of The Contact Lens Institute of Houston, has dedicated her entire optometric career to the area of specialty contact lenses. This dynamic optometrist not only battles myopia but also teaches and uplifts students. Her secret? A touch of passion, a sprinkle of perseverance—and a whole lot of dedication.

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s if by fate, Dr. Ashley Tucker’s eye care journey began right after her father was diagnosed with keratoconus, a condition that significantly affected his vision. “I attended one of his optometry appointments when I was in college and was amazed at the compassion his doctor had for him,” she shared. “My dad was undiagnosed for years. The doctor was so excited to diagnose him and offer him hard contact lenses to improve his vision.”

Her father’s vision improved from 20/50 to almost 20/15 with rigid contact lenses then. And, as the saying goes, the rest is history.

And she thought that I could add specialty contact lenses to it,” she shared. “I was nervous but took a leap of faith!”

“At that moment, I was instantly intrigued by optometry— specifically specialty contact lenses—and decided to pursue optometry,” continued Dr. Tucker, who initially was considering a career as an obstetriciangynecologist.

Before long, Dr. Tucker started reaching out to local ophthalmologists to gain referrals for specialty contact lenses. Over time, she established a good reputation and gained referrals from multiple ophthalmologists and optometrists, particularly for her expertise in specialty contact lenses and myopia management.

Dr. Tucker is a first-generation college graduate from a family with a humble background who lived Gradually, her schedule evolved to in a very small town in Louisiana. about 60% myopia management “My parents were not able to finish and specialty contact lenses. college. My dad worked his way up Because of her remarkable to the corporate office of Winn Dixie success, she bought into the —a well-known practice in 2019 grocery chain and became a “We have a vision in the south— partner of Bellaire therapy clinic, The and my mom Family Eye Care Vision Learning had a career and The Contact in healthcare Lens Institute of Center, and a billing,” shared Houston. sports vision clinic, Dr. Tucker. Xtreme Vision. We “Their hard work “We have a vision allowed them therapy clinic, The offer pretty much to financially Vision Learning everything a patient support both my Center, and a could want under sister and me sports vision through college, clinic, Xtreme one roof.” and me through Vision. We offer optometry pretty much school,leaving us with no student everything a patient could want loan debt.” under one roof,” she enthused.

Taking a leap of faith Dr. Tucker graduated with a Bachelor of Science in microbiology with a minor in health care education, before pursuing her degree in optometry. After her residency, she stayed at the University of Houston College of Optometry as a research optometrist. However, deep inside, she knew she wanted something different for her career. “A doctor whom I had interned with during optometry school asked me if I would be open to joining her practice. Her clinic specialized in primary care and vision therapy.

The profession is constantly evolving and she feels fortunate to be at the forefront of what’s happening in the world of contact lenses. “Once I started seeing mostly specialty contact lens patients, I wanted one of our names to encompass the work that I do. That’s why I came up with the name The Contact Lens Institute of Houston,” shared Dr. Tucker. While her passion lies in specialty contact lenses and myopia management, she also gained substantial experience in orthokeratology. Because of this, Dr. Tucker started to attract patients looking for myopia

management. The institute also has several ongoing clinical trials for myopia management, orthokeratology, and multifocal contact lenses.

A passion for teaching Dr. Tucker also loves teaching. In fact, she is a visiting assistant professor at the University of Houston College of Optometry, where she is the course master for the Ophthalmic Optics Laboratory. “Teaching allows me to use a totally different side of myself—the side that likes to constantly learn and evolve,” shared the mother of two. “I love connecting with students and offering them real word examples to supplement what I am teaching them.” Teaching also helps her become a better doctor. “And being a doctor makes me a better teacher. I am most fulfilled personally when I am in patient care, but I feel an obligation to my students and the profession to continue to teach. I feel very fortunate that I can do both,” she added.

A staunch crusader against myopia Dr. Tucker has also written extensively about all aspects of myopia control. According to her, the biggest challenge in myopia management is that it has not been truly accepted by patients and healthcare professionals as the standard of care. “Instead, it is perceived as a premium service that is costly and unnecessary. My hope is that we will be able to soon just provide it to all patients easily,” she remarked. Ultimately, the biggest hurdle for optometrists is educating parents about the importance of myopia control for their children. “Most parents have not heard of myopia control and think that since they haven’t experienced any pathology

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Kudos |

WOMEN IN OPTOMETRY

from their myopia, they don’t need to do anything different for their child. The truth is that many kids are on track to be more myopic than their parents, and we know that every diopter significantly increases the child’s chance of developing pathology,” Dr. Tucker explained. “Parents do want what’s best for the child, so we are obligated to make that recommendation,” she said, adding that orthokeratology not only provides effective myopia control but also frees children from daytime correction.

contact lenses, they are almost always so excited to have contact lenses as an option again or for the first time.”

A fulfilling career Dr. Tucker shared a memorable moment when a patient drove all the way from Louisiana (about 250 miles from her clinic) just to give her a thank-you gift.

“She had been suffering for years with distorted and double vision that no one could “The biggest find the answer “Many parents for. She had opportunities are come in done CT scans for presbyopic terrified about and MRIs, had patients who have their child’s numerous rounds been told that they progressive of bloodwork, myopia state. and had seen a can’t wear contact Being able to neurologist and lenses. Once I fit tell them that we cardiologist. She them with multifocal have a solution found me through and show them a friend’s referral or even monovision year after year and based on contact lenses, they that we have her symptoms, I are almost always significantly decided to do a slowed their topography and so excited to have child’s myopia found she had contact lenses as an progression is an undiagnosed option again or for the best feeling,” corneal dystrophy she continued. called epithelial the first time.” basement According to membrane Dr. Tucker, for patients who have dystrophy. After fitting her in been told that their vision issues scleral lenses in each eye, she are irreversible due to scars or was instantly able to see normally diseases, scleral contact lenses without any doubling or distortions. could be the answer. She was able to regain her life back,” she shared enthusiastically. “The biggest opportunities are Dr. Tucker is grateful for presbyopic to be able to do patients who what she does, have been which is both told that inspiring and they can’t humbling to wear contact her. lenses,” she said. “Once I “This is why fit them with I continue to multifocal educate myself or even and evolve as monovision the profession

evolves—so I can offer my patients the very best there is,” she noted. “I am not worried about competition. I just want to be the best doctor for my patients. And I will continue to grow and learn every single day for them,” she concluded.

Contributing Doctor Dr. Ashley Tucker graduated from the University of Florida with a Bachelor of Science degree in Microbiology and Cell Science in 2006, before going on to graduate from the University of Houston College of Optometry in 2010. Dr. Tucker completed a Cornea and Contact Lens Residency at the University of Houston, where she received extensive training and experience in the diagnosis and treatment of corneal diseases and complex contact lens fits. She is a partner at Bellaire Family Eye Care and The Contact Lens Institute of Houston, a private practice in Houston, Texas, where she primarily cares for patients in need of specialty contact lenses and myopia management. She is also a visiting assistant professor at the University of Houston College of Optometry, where she is the course master for the Ophthalmic Optics Laboratory. She regularly provides continuing education on the topics of anterior segment disease, specialty contact lenses, myopia management, and ophthalmic optics. Dr. Tucker is a member of the Speaker’s Bureau for the Specialty Division of Bausch Lomb, a consultant for CooperVision, and a lecturer for the STAPLE (Soft Toric and Presbyopic Lens Experience) program. She also serves as the public education chair for the Scleral Lens Education Society, is a member of the advisory board for the Gas Permeable Lens Institute, serves on the AOA Contact Lens and Cornea Section, and is on the Program Committee for the Global Specialty Lens Symposium. She is also a regular columnist for Contact Lens Spectrum. ashley.w.tucker@gmail.com

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Innovation |

CONTACT LENSES TECH

monitoring and the impact this could have on a large portion of the population.

From AR to Night Vision What does the future of contact lenses look like? by April Ingram

In the not-so-distant future, the eyesight superpowers once confined to Marvel Universe characters could be available to us mere mortals. And it could all be as simple as wearing your daily contact lenses. We dive deep into the future of contact lenses—some of which are already ready for prime time.

he functionality of contact lenses is transcending imagination, with several companies making leaps and bounds with some seriously spylevel innovations on the horizon! Technology giants such as Samsung and Sony have investigated contact lenses that have their own cameras and can record video. Researchers from the University of California have even developed robotic contact lenses that can be commanded by blinking to zoom in up to 32%! And how about ditching the night vision goggles for thermal-sensing or graphene night-vision contact lenses? The University of Michigan is studying this technology, which has useful applications in the military, as well as wildlife and conservation.

Beyond smart contact lenses With the release of smart glasses, people had access to a world of information right in front of their eyes. But with smart contact lenses, they bring all of this information directly into the wearer’s visual field. In addition to enhancing the sense of sight, smart contact lenses can also tell you, or your healthcare provider, all about your eye health! Upcoming technologies utilize an array of sensors, accelerometers and displays as part of the experience, and apply the technology to assess key features of your tears, providing real-time monitoring of salts, proteins, metabolites and enzymes. A big draw to this sort of healthcare is the prospect of continuous glucose

Dr. Yangzhi Zhu, an assistant professor at the Terasaki Institute for Biomedical Innovation in Los Angeles, California, whose work focuses on soft materials and wearable bioelectronics for diagnostic and therapeutic applications, has been watching the promises and pitfalls of contact lens technology over the years. “Smart contact lens has evolved to serve as a wearable intelligent ocular prosthetic device capable of noninvasive and continuous monitoring of essential physiological and chemical biomarkers and therapeutic delivery for personalized ocular and systemic healthcare management,” Dr. Zhu shared. However, before we all rush in to our optometrists demanding our superpowers, Dr. Zhu recognizes that from a practical standpoint, there are development hurdles that still need to be cleared before this technology can go mainstream. “There still is a long way to go to achieve better practicability and even final commercialization,” he said. “For example, contact lens-induced dry eye and other symptoms are still a primary reason that stops users from using them.” It would be a big step forward in healthcare if wearable technology could reliably monitor multiple aspects of patient health. But we need to make sure the results we receive are accurate. While Dr. Zhu recognizes the potential benefits of smart contacts, he still has certain concerns regarding their biomedical applications. “For the contact lens biosensing system, we agree that it would create a huge success if we could use wearable tear tests to replace blood tests, because wearable tear analysis with smart contact lenses can achieve continuous and non-invasive monitoring of multiple essential biomarkers from the tear,” he explained. “However, the question is

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Innovation |

CONTACT LENSES TECH

whether there is a robust correlation between biomarkers in the tear and biomarkers in the blood.”

breathability, flexibility, and the cost of the lens, could be critical concerns,” he said.

He shared the example of Google’s smart contact lens project in 2014. “This project aimed to assist people with diabetes by constantly measuring the glucose levels in their tears. Later, Verily terminated this project because of the lack of correlation between tear glucose and blood glucose,” he said.

Bear in mind that we are talking about a foreign body that users will need to insert into their eye. So understandably, they won’t pay thousands of dollars if it isn’t comfortable, or even worse, if it could be potentially harmful to the eye.

Although Mojo Vision’s Mojo Lens was thought to be near-ready for the Such a lack of correlation could real world in early 2022, the company have severe has since pivoted, consequences, focusing more “AR, or humanespecially for heavily on its micromachine interface, patients whose LED technology lenses have also treatments would instead—putting be based on levels lens development received much indicated by their on the back burner attention in this field. contact lenses (for now). Mojo was a new instead of what their body truly startup pioneering Drug-eluting required. this technology due contact

Are we ready for AR lenses?

to their expertise in advanced microLED and macro fabrications.”

Another avenue of research is augmented reality (AR) contact lenses, which promise to deliver a more immersive experience for the user without the need for glasses or cumbersome virtual reality headsets. These lenses overlay what you already see with messages, directions or other helpful details, eliminating the need to continuously check a smartphone or other device. “AR, or human-machine interface, lenses have also received much attention in this field. Mojo was a new startup pioneering this technology due to their expertise in advanced micro-LED and macro fabrications,” Dr. Zhu shared, describing one company working with AR technology within a contact lens.

The prototype Mojo Lens (Mojo Vision, California, USA) included a 4,000-pixel-per-inch "screen" with onboard power and communications. Dr. Zhu noted some of the challenges companies like Mojo have encountered: “Integrating electronic components, user comfort, functional stability, transparency, biosafety,

lenses are here!

Patient compliance has consistently posed a challenge for optometrists. Although ODs may prescribe topical drops to be administered three times daily, they often must bear the consequences of patients only managing one or maybe two drops per day—if luck is on their side. Imagine a world where there’s no need to pry pinched eyelids open in the hopes of getting a single drop of medication to reach the eye surface. What if the exact intended dose could be delivered by a contact lens? In fact, this is not a contact lens of the future—drug-eluting lenses are actually part of the here and now. “A drug-eluting contact lens containing an antihistamine for people with allergic eye itch won approval from the FDA,” Dr. Zhu reported. “This drug-eluting contact lens with ketotifen (Acuvue Theravision; Johnson & Johnson Vision Care, Florida, USA) is the world's first drug-eluting contact lens.”

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He added that this has been a long time in development. “The concept of drug-eluting contact lenses is not new—it was reported as early as 1960. The current challenge, however, is to achieve a sustained, long-term drug delivery with zero-order kinetics at the normal physiological temperature, pH and salinity of the human eye,” Dr. Zhu explained. “Another concern is to find the practical unmet need of the drug-eluting contact lens, although we identify several advantages compared to eye drops.”

The future of super vision Finally, we asked Dr. Zhu about the direction of all these developments and how he sees them breaking into healthcare and eye care delivery in the future. “Along with technological developments such as the miniaturization of electronics, the development of artificial intelligence, and the popularization of AR, increasing public interest in personalized medicine has been accelerating the development of smart contact lenses,” he shared. “In this respect, it can be said that the smart contact lens, a ‘visible medical device’, has reached a crucial point more than ever and will play an essential role in the future,” he concluded.

Contributing Doctor Dr. Yangzhi Zhu is an assistant professor at the Terasaki Institute for Biomedical Innovation. He received postdoctoral training at the University of California, San Diego, in 2020. Before that, he obtained his PhD at the University of California, Riverside, in 2019. His recent work focuses on wearable medical devices for diagnostic and therapeutic applications. yzhu@terasaki.org

Enlightenment |

The Battle Against Eye Care Waste How to tackle the environmental issues posed by contact lenses—and the role optometrists and the eye care industry have to play in mitigating them by Joanna Lee Though disposable soft contact lenses like dailies may only be a transient moment in the life of the wearer, their relationship with the planet is far more toxic. Due to their composition, contact lenses are not completely biodegradable—and this is hurting our planet.

earing contact lenses impacts our environment more than we realize.1 Researchers in the US have found that up to 19% of surveyed contact lens wearers dispose of their lenses by flushing them down the sink or toilet. This results in an estimated total of 3.36 billion lenses being flushed into the sewage system annually.2 There are many layers to the harm that disposable contact lenses can cause to the environment. When contact lenses are disposed of, they undergo chemical interactions with microbes commonly found in wastewater. This process leads to

the disintegration of the particles in contact lenses, resulting in microplastics1, which can wreak havoc across a broad range of the planet’s systems. For example, marine animals may mistake these invisible microplastics for food, eventually finding their way into our food chain.

A critical issue at hand Considering the growing trend in contact lens prescriptions, will this issue continue to pose a threat to humans and aquatic life? In 2019, there were already around 150 million contact lens users worldwide, and the number has

CONTACT LENS DISPOSAL

continued to climb steadily over the last two decades.3 In particular, the use of daily disposables has grown twice since 2000, and there has been a spectacular increase in silicone hydrogel lens fittings as well. Different categories of contact lenses produce different amounts of plastic waste. An earlier study looked at conventional systems (hard contact lenses), planned replacement systems (monthly disposable lenses), and daily disposables. The findings showed monthly disposables—which the researchers have defined as 12 lenses including a cleaning solution, and lens cases—generate the least waste (549 grams) compared to hard contact lenses (1,893 grams). This is because hard contact lenses category of usage is often bound together with the usage of its particular range of care supplies as well—for instance, saline, peroxide cleaners, contact lens cases, and other related items. Daily disposable systems, according to the study, produces 953 grams of plastic waste altogether. Interestingly, an Arizona State University study4 estimated that nearly 21% of single-use disposable contact lenses users flush down their lenses, which could contribute to as much as 23 metric tons of plastic waste annually in the American wastewater system. Contact lenses in the wastewater were determined to break down into smaller fragments of microplastic which pose a risk of leaching into agricultural soil or into rivers and oceans when it rains. This was a first-of-its-kind study which attempts to measure the impact of contact lenses on the environment. Furthermore, what presents a challenge in recycling contact lenses is their composition, which is based on different types of polymers and silicon that are distinct from typical household plastics that are relatively easier to recycle. Essentially, these are medical-grade plastics that are designed to endure harsh conditions.

Facing the issue head on As concerns about the increasing accumulation of plastic-related wastes grow, the optometry industry

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Enlightenment |

CONTACT LENS DISPOSAL

and practitioners are stepping up to the plate in all efforts to reduce the environmental impact of microplastics. In the United States, Bausch + Lomb has partnered with TerraCycle, a notfor-profit company that specializes in recycling hard-to-recycle plastics and materials, to launch the ONE by ONE Free Recycling Program. In the scheme, TerraCycle collects contact lenses and blister packs at various drop-off points via local optic shops that have opted to join the program. More and more eye care professionals are picking up the torch and turning their shops into dropoff points for the recycling program. Since the partnership’s launch, the company reported that it has collected more than 41 million units of used contact lenses along with top foils and blister packs.4 And together with its newer program, the Biotrue® Eye Care Recycling program, it has recycled 41,358,603 units of used contact lenses and eye care material thus far.

Reducing carbon footprint In addition to recycling, manufacturers also focus their efforts on reducing their carbon footprints during manufacturing processes and when designing contact lens packaging. For instance, Johnson & Johnson Vision Care’s improved manufacturing process for Acuvue Oasys with HydraLuxe has contributed to a 12% reduction in energy usage.

It also won an Environmental Leader Award in 2017 for its Acuvue Oasys 1-Day daily contact lenses that use 100% sustainable packaging with paperboard purchased from a Fiber Sourcing Certified plant. This green packaging has translated into a reduction of 57 tons in paper usage, and its lighter weight has resulted in 13% less energy usage during shipping and distribution. Other contact lens manufacturers, such as CooperVision and Menicon in Japan, are also joining the sustainability movement by engaging in contact lens recycling initiatives.5 In Singapore, Capitol Optical has staked its claim as the country’s first contact lens recycling program, which helps to recycle foils and blister packs derived from sanitized aluminum and polypropylene. However, recycling contact lenses themselves has not been allowed yet by local authorities.

Pioneers of eco-friendly practices in the region Programs like these are seeing practical enforcement and support in the industry. Dr. Jason Teh talked about the availability of a contact lens recycling bin at his practice, In2Eyes in Melbourne, Australia. “This is provided by contact lens companies in partnership with a recycling business, for example, Bausch + Lomb with TerraCycle,” he said. “Patients can collect and bring the waste back when they come for follow-up appointments or to pick up

their next contact lens supplies,” he shared. He added that this helps to bring awareness to patients regarding the impact of contact lenses on the environment. “We also promote ortho-k contact lenses as an option, which allows patients to use the same hard lens for two years. This is a convenient and excellent reusable option,” Dr. Teh continued. Similarly, Mr. Ryan Ho from Malaya Optical in Petaling Jaya, Malaysia, agrees with advocating for longerwear lenses, such as the RGP lenses, and those lenses designed for ortho-k fitting procedures. Admittedly, noted Mr. Ho, awareness among Malaysian contact lens users about the environmental impact of contact lens waste is not high enough. “We know that plastic straws and plastic bags aren’t being reused, so they need to be recycled. Why not reduce the impact of contact lenses on the environment as well? Upon realizing how microplastics from contact lens waste could adversely affect us after entering the wastewater system, we would want our optometrists to educate patients not only about the hygienic practices of contact lens use but also about recycling their contact lenses,” Mr. Ho explained. In India, Dr. Monica Chaudhry painted a different picture that is perhaps representative of numerous Asian countries like her native India—there is room for improvement when it comes to contact lens usage and environmental awareness. She shared that plastic consumption in India remains relatively low per capita (11 kilograms per year compared to America’s 109 kilograms per year).6 However, an estimated 40% of its plastic waste is neither collected nor recycled and with a large population, this could have major repercussions on the environment. In 2022, however, the government imposed a ban on singleuse plastic to combat the issue of plastic pollution.7,8 “Considering all these, even contact

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lenses should be recycled. But I’m not sure if any of the practitioners in India are segregating them into bins nor advising our patients to do the same,” she shared. “However, your article could, at the very least, initiate the thought process to do so,” Dr. Chaudhry honestly remarked.

References 1. The Environmental Cost of Contact Lenses. Available at https://www.eurekalert.org/newsreleases/487439. Accessed on August 10, 2023. 2. ASU scientists report 1st nationwide study showing environmental costs of lenses. Available at https://news.asu.edu/20180819-discoveries-asu-scientists-1st-nationwide-study-environmentalcosts-contact-lenses. Accessed on August 10, 2023. 3. Morgan PB, Efron N. Global contact lens prescribing 2000-2020. Clin Exp Optom. 2022;105(3):298-312. 4. Environ. Sci. Technol. 2020, 54, 19, 12102–12108, Publication Date:September 1, 2020 https://doi.org/10.1021/acs.est.0c03121 5. Bausch + Lomb Reports More Than 41 Million Units Of Contact Lens, Eye And Lens Care Materials Recycled Through ONE By ONE And Biotrue® Eye Care Recycling Programs. Available at https://ir.bauschhealth.com/news-releases/2021/11-15-2021-115913359. Accessed on August 10, 2023. 6. The Environmental Impact of Contact Lens Waste. Available at https://www.clspectrum.com/ issues/2019/august-2019/the-environmental-impact-of-contact-lens-waste#reference-25. Accessed on August 10, 2023.

Contributing Doctor

7. Plastic bans spread in India. Winners and losers aren't who you'd expect. Available at https:// www.nationalgeographic.co.uk/environment/2019/02/plastic-bans-spread-in-india-winners-andlosers-arent-who-youd-expect. Accessed on August 10, 2023.

Dr. Monica Chaudhry is a consultant optometrist and educator who has more than three decades of experience as an academic and clinician. With her extraordinary skills in optometry education, she has recently ventured to be a freelancer educator, strategy advisor, and practitioner. She is the founder of an online optometry upskilling education platform, Learn Beyond Vision. Also, she has instituted some centers of excellence and vision centers, which aim to be a unique referral, academic and research units. She is well-known contact lens and low vision specialist and has a far and wide patient referral in India. Dr. Chaudhry has served at the All India Institute of Medical Sciences (AIIMS) in New Delhi, had academic experience with various universities, including the Indira Gandhi National Open University (IGNOU) and Amity University (India), and has recently retired as director of School of Health Sciences at Ansal University (Gurgaon, India). In recognition of her contribution to the field of academic medical service, she has been awarded the Shreshtshree Award by the Delhi Citizen Forum, the Australian Leadership Fellowship award in 2012 and the IACLE Contact Lens Educator of the Year (Asia Pacific) award in 2015. Dr. Chaudhry was chairman of the Optometry Council of India. She has been actively involved in organizing conferences, seminars, national and international workshops, faculty development programs and many corporate training programs.

Mr. Ryan Ho first undertook a Bachelor of Science in Microbiological Sciences at the University of Kansas, USA, in 1996 before studying Optometry at the International University College of Technology Twintech, Malaysia, in 2008. He is a skilled optometrist with over 15 years of experience. He obtained his first degree in B.Sc. at the University of Kansas, USA, and continued to pursue his passion for his Bachelor of Optometry (Hons) in Malaysia. His opinions on the treatment of Ortho-k, monovision, progressive lens fitting, and myopia in children have been well sought after on national television stations, such as RTM, TV3, and national newswires, as well as publications such as Bernama, The Star, and more. He has helped build Malaya Optical from a family-owned business of three generations to become a two-time award winner of the prestigious Brand Laureate Award. While he is busy running his retail practices, online store, and building an eyewear brand, Mr. Ho makes sure to spend quality time with his family as they are the inspiration behind this brand. During his leisure time, Mr. Ho enjoys riding his road bike on numerous road adventures.

monica.rchaudhry@gmail.com

ryan@malayaoptical.com

8. ndia bans single-use plastic to combat pollution. Available at https://www.reuters.com/world/ india/india-bans-single-use-plastic-combat-pollution-2022-07-01/. Accessed on August 10, 2023.

Dr. Jason Teh is a dedicated practicing optometrist. He is the founder and director of the Dry Eye Group in Melbourne, Australia, a comprehensive diagnostic eye clinic with a vision and commitment towards a variety of advanced treatment options in dry eye disease (DED). A long-standing member of the Optometry Australia Association, Dr. Teh was also a graduate of the University of Melbourne with a B.S. in Pharmacology (Hons) in 1998 and a Bachelor of Optometry in 2001. Having lived with DED himself for more than 25 years, Dr. Teh specializes in its management. Passionate about improving lives through better vision and eye health, he is also committed to educating his patients on the causes of their dry eyes and helping them manage their symptoms through preventative and modifying lifestyle measures. He is proud and most fulfilled by his contribution to the growth of the optometry industry by running dry eye workshops, lecturing on DED at various conferences, performing clinical research trials of new dry eye products, and assisting his colleagues to establish their own dry eye clinics. jason@dryeyegroup.com.au

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Enlightenment |

ATROPINE

results than their counterparts in the atropine cohort, and that atropine doesn’t slow myopia progression or axial elongation in US children.1 Furor sparked, indeed.

Compare, contrast, and confirm the results

A Look at Atropine Three-year study reports atropine is less effective than placebo in myopia control by Andrew Sweeney

Atropine has recently gained popularity as a treatment for myopia. However, a new study has found that a placebo group experienced greater efficacy compared to subjects treated with atropine. We spoke with Dr. Sun Chen-Hsin, a myopia specialist based in Singapore, about the results of the study, what they mean for patients, and the future of atropine treatment.

oming to an unexpected result is a common experience when carrying out a research project. However, a conclusion that causes real surprise among one’s colleagues is relatively rare. Even more so when the results in question could cause a drug’s approval by the US Food and Drug Administration (FDA) to be delayed. The authors of the study, Low-Dose 0.01% Atropine Eye Drops vs. Placebo for Myopia Control,1 may not have expected to generate a minor furor when they set out with their study. The project was run as a randomized placebo-controlled, double-masked

clinical trial from June 2018 to September 2022. Children aged five to 12 years were recruited from 12 community and institution-based practices in the United States. All participants had low to moderate bilateral myopia -1.00 to -6.00 diopters.1 The study’s concluding remarks were stark: “The results do not support the use of 0.01% atropine eye drops nightly to slow the progression of myopia in US children.” In fact, the study found that children in the placebo group reported better

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"The 0.01% atropine study was published on the JAMA Network, a reputable organization sponsored by the National Institute of Health, and it has a fairly standard design. At first glance, you would not think that there is a problem with it, but if you examine it in more detail, you can explain the surprising results," said Dr. Sun Chen-Hsin, a clinical engineer at the National University of Singapore and a specialist in myopia treatment. When Dr. Sun first read the results of the Low-Dose 0.01% Atropine Eye Drops vs. Placebo for Myopia Control study, he was surprised at atropine’s poor performance. There was, however, something familiar about the methodology behind the study that made him wonder how its results were ultimately confirmed. Dr. Sun realized that he had seen a similar study that would help explain why the placebo group could have been more effective than the atropine cohort. The study, Efficacy and Safety of 0.01% and 0.02% Atropine for the Treatment of Pediatric Myopia Progression Over 3 Years,2 was published just over a month before the previous aforementioned study on atropine. The two studies may be similar but one recorded a stronger result for the placebo group, whereas the other concluded that “results of this randomized clinical trial suggest efficacy for low-dose atropine at 0.01%.”2 Dr. Sun wondered what could account for the difference. He found that the answer was within in the second group surveyed in the slightly older study. That was because this research project also examined patients who received eye drops at a concentration of 0.02%, which recorded poorer results than both 0.01% and more crucially, the 0.00% group.

This struck Dr. Sun as odd, especially as the 0.01% cohort performed well. Examining the study to discover why this was the case, he concluded that the disparities were due to differences in the baseline sample characteristics, especially as the study’s participants had a large age range, from three up to 16 years old.2

Age, ethnic background, and time spent outdoors “When you have an age range that is that huge, then the progression for these kids is going to be very heterogeneous as a 16 year old is not going to progress as much as a three year old. You can try to match the placebo group and treatment group so that they have the same average age, but the bracket of the number of participants in each age group will not be the same,” Dr. Sun said. This led Dr. Sun to investigate the baseline statistics of the first study that examined 0.01% atropine alone over three years, and he realized why the placebo performed more effectively. His first discovery was that the age group was as wide as the 0.02% study, which would make a positive result for atropine less likely.

“The ramifications of the study’s results are that atropine may not be likely to get FDA approval, at least in the short term. There is also going to be considerable momentum to do another study on the medication, so as a result, FDA approval may not happen for some time.” The 0.02% study, despite being primarily carried out in the United States and the United Kingdom, had a high share of East Asian participants, at 50%. Dr. Sun believes this may have skewed the results of the study as this ethnic group is significantly more likely to experience myopia. However, he emphasized that this

should be seen as a contributing, rather than a definitive factor.

not happen for some time,” Dr. Sun explained.

Dr. Sun believes that the main issue with these atropine studies was that they did not take into account lifestyle factors, like time spent outdoors and the amount of time spent per day looking at computer screens, which are both proven to have a direct link to myopia progression.3 Both studies were also conducted throughout the COVID-19 pandemic in countries that underwent strict lockdown procedures. During this time, patients would have become more susceptible to myopia, as they were stuck inside, frequently glued to electronic devices.

“Many countries look to the FDA for guidance in terms of approval for their local market. So if there is no FDA approval, then a lot of countries will just not want to use atropine,” he concluded.

Fears for atropine’s acceptance by the FDA

References

Dr. Sun remains a proponent of atropine, pointing to a considerable body of research that supports its efficacy. He also reports his own anecdotal experience of using the medication in a case involving a sixyear-old child who developed myopia in one eye (with a diopter of -0.1), for whom he prescribed 0.01% atropine. The child’s other eye began to develop myopia. However, the parents decided (erroneously) to only treat the original eye with atropine. Within six months, the original eye remained at the same level, whereas the untreated myopic eye had reached a diopter of -1.5. He is concerned, however, that a placebo being recorded as more effective than atropine in one study could prove to be a major stumbling block toward its full acceptance by international ocular healthcare. The issue is particularly acute as the medication is currently being considered by the FDA for full approval. “The ramifications of the study’s results are that atropine may not be likely to get FDA approval, at least in the short term. There is also going to be considerable momentum to do another study on the medication, so as a result, FDA approval may

Editor’s Note A version of this article was first published on cookiemagazine.org.

1. Repka MX, Weise KK, Chandler DL, et al.; Pediatric Eye Disease Investigator Group. LowDose 0.01% Atropine Eye Drops vs Placebo for Myopia Control: A Randomized Clinical Trial. JAMA Ophthalmol. 2023;141(8):756765. 2. Zadnik K, Schulman E, Flitcroft I, et al.; CHAMP Trial Group Investigators. Efficacy and Safety of 0.01% and 0.02% Atropine for the Treatment of Pediatric Myopia Progression Over 3 Years: A Randomized Clinical Trial. JAMA Ophthalmol. 2023;e232097. [Online ahead of print] 3. Lee SS, Mackey DA. Prevalence and Risk Factors of Myopia in Young Adults: Review of Findings From the Raine Study. Front Public Health. 2022;10:861044.

Contributing Doctor Dr. Sun Chen-Hsin is a clinicianengineer who 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 his Doctor of Medicine degree from Duke-NUS Graduate Medical School. Dr. Sun has a particular interest in managing progressive myopia in children and developing pediatric ophthalmology medical devices. He currently works at the National University Hospital Singapore. sun.chen.hsin@gmail.com

COOKIE MAGAZINE | October 2023